| Geriatric Care Managers Lead Highly Skilled Teams |  |
| Geriatric Care Managers Lead Highly Skilled Teams | |
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Success Story: Balancing Care and Independence |
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by Rosemary Kuhn, RN, CCMAfter spending one week in the hospital and four weeks in a rehab unit, the very independent, 92-year-old Mrs. White was scheduled to be sent home alone. She was alert and oriented, albeit very frail. Her children, who live in different states, contacted RBA/SB for care management. Although Mrs. White was extremely resistant, she eventually was able to listen to her children’s wishes and agreed to let a Care Manager take her home and assess the situation. Our Care Manager met with Mrs. White at the center, reviewed her medical chart, and brought her home. Mrs. White and her family insisted she was well enough to be left alone, refusing any further help. The Care Manager visited Mrs. White the next day to discuss a plan for her current and future needs. Mrs. White had been diagnosed years earlier with chronic leukemia and is checked regularly by an oncologist/hematologist. She usually presents anemic with a low hemoglobin and hematocrit, for which she takes daily iron. Mrs. White also has congestive heart failure, hypertension, glaucoma, poor eyesight, and had recently lost weight. She had not been to her primary care physician in more than a year. Our Care Manager recommended a geriatric specialist and made an appointment. Our Nurse Care Manager was scheduled to set up medication management every two weeks. As for her day-to-day care, Mrs. White said she paid the security guard at her townhouse development to grocery shop for her weekly and that his wife cleaned her home. The Care Manager had some safety concerns and arranged for the installation of grab bars in the bathroom and the living room where she had previously fallen. The Care Manager noticed that Mrs. White seemed extremely overwhelmed and easily fatigued. Although Mrs. White is highly independent, the CM felt that she was greatly at risk due to her age and weakened condition. Mrs. White still resisted having a home health aide. The next day, when the CM came to take her to her doctor’s appointment, she found Mrs. White on the floor. She had fallen again, and although she did not appear to be hurt, the CM called 911. Paramedics checked her vital signs and said she was all right. The CM discussed safety issues with Mrs. White and insisted that she permit a live-in aide at least until she was stronger. Mrs. White reluctantly agreed. The CM accompanied her to her new doctor the next day, who felt she was doing well. He ordered blood work and requested her medical records, but did not order any changes in medication, wanting to review her records first. Before her follow-up appointment, Mrs. White was back in the hospital. She was very weak and had severe diarrhea. After five days, she was discharged to home. The doctor recommended a gastroenterologist, and an appointment was made. However, before the appointment, Mrs. White began having abdominal cramping, very loose to pasty, tarry stools and bleeding. This required a visit to the emergency room for evaluation. These episodes, while frightening to Mrs. White, reinforce why she must not live alone. Medicare home health was ordered to carefully to monitor her progress. Mrs. White’s adjustment to having a live-in aide has not been smooth. She has been very unsure about what the aide should be doing, leading to frustration for the aide and the client. Although there are still many adjustments to be worked out, Mrs. White ultimately grasped the reality that she would only be able to maintain her independence if she accepted help. |
About SeniorBridge
Why put the care of your loved ones with SeniorBridge? Our company’s unique approach addresses the total well-being of clients and their families through a comprehensive program that includes assessment, planning, service coordination, advocacy, and direct care by an interdisciplinary team led by a geriatric care manager. Read More About Us |
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