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Partnering with a Care Manager

By Rona S. Bartelstone, LCSW, BCD, CMC

(Page 1 of 3)

Caregiving is never easy and it takes many people to provide the appropriate support services for all. Traditionally, we think of the physician as the point person for primary care. However, with all of our medical advances, most diseases have become chronic illnesses that require a range of health, social, emotional, environmental and physical services in addition to medical care. Since the health and social service systems are fragmented and difficult to navigate, private care management has evolved to create a partnership that guides families through the caregiving process.

This partnership between the care manager and the family facilitates the coordination of appropriate care at the appropriate time, in the right setting and in accordance with the preferences and resources of each situation. What a colleague of mine calls the “Goldilocks” approach to individualizing care for each situation. Rather than trying to describe the partnership between the family and the care manager, below is an actual situation that resulted in assuring that the care recipients were well provided for, the family was given peace of mind, and the doctor had someone who could assure that his plan of care was actually being implemented in the home.

One Family’s Story

Mr. and Mrs. Chasser (not their real name) were faced with multiple care decisions as they were living in South Florida away from their family and beginning to deal with long term care needs. They were a worldly couple who had saved enough financial resources to meet their needs in retirement. They had done some traveling and were now content to stay at home as they began to experience some physical and cognitive changes.

Mr. C was 82 and relatively healthy, though he was beginning to experience some memory loss. For this reason he had asked his wife to take over the daily money management. Mrs. C was 80 and had a heart condition for many years. She began to tire more easily. She also had some osteoporosis that caused discomfort and limited her ability to walk long distances.

Mrs. C was also becoming increasingly anxious. She remembered her mother-in-law’s “senility” and feared this was happening to her husband. She had never had to be responsible for money management, investments or legal issues and did not know what she would do if her husband lost his ability to handle these needs. On the other hand, she was afraid to ask him to teach her because he was very sensitive about his memory loss and she did not want to upset him.

After a trip to visit their grandchildren, Mrs. C experienced a stroke that caused her to become very weak and she lost her language. Although she was expected to regain some of her mobility and speech, she would never be as active again. While Mrs. C was in the hospital and rehabilitation center, Mr. C realized that he could not manage at home alone. He was unable to take care of the shopping, meal preparation, laundry or housekeeping. He also had difficulty dressing himself because his wife had always laid out his clothes for him. He became very frightened and began to knock on the neighbors’ doors at all hours of the day and night.

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