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Partnering with a Care Manager

By Rona S. Bartelstone, LCSW, BCD, CMC

(Page 2 of 3)

Finally, one neighbor called the Chasserís son to express her concern. The son had not been aware of the extent of his fatherís memory loss or his inability to manage at home alone. Mr. C kept telling his son, Brian, that he was managing just fine. Brian flew in to visit his parents, as planned, when his mother was going to be discharged from the hospital to a long term care facility for rehabilitation. Upon arriving at his parentís home, Brian found his father sitting in the dark crying because he could not remember when his son was coming and he thought that his wife had already been moved and he could not remember where she was sent. Furthermore, there was no food in the house, which was unkempt and Mr. C was wearing dirty clothes. Brian suspected that his father hadnít bathed in several days.

While the hospital social worker was able to assist Brian with his motherís care, she was unable to help with his father because he was not a patient. She suggested that Brian hire a private care manager, who would be able to help him coordinate the care of both parents regardless of the settings they were in. The care manager could also help with integrating the different services and payer sources to provide the optimal plan most efficiently.

The care manager spoke with Brian and discovered that there were several levels of need and a variety of sources of support for his parents. After an assessment of each parent, the care manager helped Brian to determine the best care for his parents at this point and to help him identify what the future needs might be as well.

Mrs. Chasser did go to a rehab facility where her care was covered by her Medicare and supplemental insurance policies for two weeks. Depending upon her progress, the care manager would help the family determine if she should stay in the facility or come home to continue therapy. Because the Chassers had a long term care policy, they would be able to continue rehabilitation beyond the Medicare benefit period.

Mr. Chasser also needed extensive care. The care manager felt that Mr. C was experiencing an exacerbation of his cognitive losses because of the stress of his wifeís illness that was causing him to feel frightened and stressed to the point of depression. The care manager arranged for a complete neurological and psychiatric work-up through a local memory disorder center. This resulted in a diagnosis of probable Alzheimerís disease. This diagnosis qualified Mr. C to access benefits for home care under his long term care policy as well. An aide was placed with Mr. C at home on a twenty four hour basis. This was seen as temporary until his wifeís plan of care was more definite.

The care manager also arranged community services for Mr. C. It was felt that he could benefit from a day care program to provide him with stimulation and socialization, while his wife was in treatment. A medication dispenser was brought into the home to assure compliance with medication routines. Grab bars and a shower seat were added to the bathroom to make it safer. A personal emergency response system was installed in an effort to determine if Mr. C could learn to use it in anticipation of his wife returning home and the possible need for this service.

 

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