Care Coordination
Care coordination is perhaps the biggest issue facing family caregivers, especially if a loved on his hospitalized. That is when it is important to pick a great primary care physician who can serve as your medical home. This will smooth transitions and assure that your loved one does not fall through the cracks. Sometimes you have to reach out for help. That is when the services of a geriatric care manager can be invaluable. You may also consider a patient advocate who can help too. Let’s look at these issues.
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The best facilities I’ve worked for had excellent Care Plan teams, of which I was fortunate to be a part. I’ve found hospitals are not as diligent, and living more than 2 hours from my own mom, am very frustrated that the hospital and facility case managers are not as helpful as they use to be. We’re in the midst of a scary situation right now after two recent hospitalizations for my step father, and no communication between the nursing facility and hospital at all. The facility doctor doesn’t even have rights in the hospital the facility sent my step father to, so there is no communication between doctors, and while the hospital case manager is releasing him to a special treatment center for a staph infection he got while in the hospital, the nursing home case manager is requiring my mom give up his bed at the nursing home, and there is no plan of action past the 6 weeks he will be at the special treatment center. This is not the kind of care we gave when I worked in LTC, and it is no wonder our healthcare cost are so incredibly high, with repeat hospital visits due to lack of care planning and management. Luckily, I have a social work friend from my LTC days living in my mom’s area, who has offered her help to sort things out. But I fear for those who don’t have an advocate at all.
Thanks for your insights Julie. Most appreciated.