Rona S. Bartelstone, LCSW, MSW, CMC Senior Vice President of Care Management

Technological advances in the delivery of health care, combined with shorter hospital stays, limited discharge planning and expansion of home care technology, have transferred the responsibility for the care of frail elders and persons with disabilities onto families. With little or no preparation, training or support, family members must now assume a health management role at home and carry out tasks traditionally carried out by health care providers. This combined with the fact that older people are now less likely to have family close by, makes having a support system more important than ever.

SeniorBridge CareManagers, with training in health and social services, provide high touch care, as well as advocacy, training and emotional support to older adults, the disabled and their families. They often serve as the point person to identify and coordinate information, health care and home and community-based services.

Family caregivers tend to be at greater risk for stress-related illnesses and mental health problems, including increased risk of mortality. Sustaining family caregivers and their ability to provide care at home or in the community is crucial, whether the family is on site or caring from a distance.

This is the role of the SeniorBridge Care Manager.

Most often, a Care Manager is hired by a family member or person in a fiduciary capacity to act in their stead when they cannot be present to coordinate and manage the logistics of care.

The Care Manager works with the health care team and providers to coordinate the appropriate provision, supervision, compliance and follow-up of medical, social, emotional and safety needs. In addition, the Care Manager provides education and emotional support to help cope with the stresses of compounded losses and grief.

The professional Care Manager assures compliance with the physician’s plan of care in the home environment. This includes monitoring medication routines, reviewing and improving safety concerns, assuring compliance with high-tech treatments and therapies and following up with physicians. Often the Care Manager will become aware of issues that arise only in the home care setting and can provide this information to the physician, paving the way for necessary consultations and/or treatment.

Care Managers can be especially helpful when the patient and/or caregiver have cognitive limitations. In these situations, especially in early dementia, the patient is able to compensate enough that the doctor may be unaware of functional decline or impaired decision making. Likewise, the family caregiver may attribute cognitive or functional changes to the "normal aging" process. When this occurs, the physician does not receive an accurate picture of the deficits and needs of both the patient and family caregiver.

The high touch approach of the Care Manager facilitates a holistic, personalized approach to patient care. As we move into a technological age, let’s not overlook the need for emotional support and human connection—the backbone of the Senior Bridge approach to care.