Where do you get the interventions or solutions for the problems listed in your care plan? In part, you take them from the continuum of care. What is the continuum of care? It is all the resources for aging adults in your services area. The continuum of care ranges from hospital discharge planners, doctors, elder law attorneys, trust officers, to plumbers, licensed contractors, private duty home health agencies, moving specialists, senior technology teachers, caregiver support groups. It is the body of knowledge of resources you know as a geriatric care manager or aging professional to fix the problems you have just outlined in your care problems.
Every geriatric care manager or aging professional must know a staggering array of other experts who make up the web of senior services in the community. These experts practice in areas to which GCM skills do not extend (attorneys, trust officers, moving companies, plumbers). It is the care manager’s expert knowledge of the continuum of care in the community that is the heart of the care management role. As stated I have blogged before, a Geriatric care manager or aging professional is like Charlotte, the friendly spider. The GCM runs across the web of senior services (continuum of care), linking services, repairing gaps, spinning new solutions, and coordinating answers. You need to know how to locate all those services to implement your care plan and find interventions to the problems you have uncovered.
How do you connect aging client assessments? For example, if you find through your functional assessment that the client’s clothes are dirty and they are not bathing, start with self care deficit in your care plan then list that manifestation of the problem. If you find your caregiver assessment that the family caregiver is depressed and angry and is on the edge of placing the older person even if they are at the level of care- start with caregiver burnout and then list the manifestation of that burnout. You have then connected two different assessments.
Frequently, many older clients have similar deficits as they age. Most care plans will include one or more of these problems, and it is good to incorporate this list into your psychosocial and functional assessment tools. These can become a pick list you can add to the beginning of your care plan because many of them will appear in your care plan.
What is the next step in creating a care plan? You started with the initial reason the family member or client called you as a geriatric care manager or aging professional. The first assessment you turned to is your functional assessment. After addressing the first problem, you continued creating your care plan by listing the client’s problems from your functional problems.
Next you list the psychosocial problems taken from your psychosocial assessment. Say our Parkinson’s client’s adult children are arguing about whether to place him at a higher level of care or keep him at home. This would be a psychosocial problem and a family meeting initiated by you the GCM or aging professional would be the intervention in your care plan. Perhaps our older client is living with an older woman companion and the adult children suspect her of trying to get their father to change his trust in her favor. That would be a psychosocial problem and the solution would be to identify your Parkinson’s client elder law attorney and, with the adult children’s consent, set up a meeting with the family and the elder law attorney to discuss their concerns about fiscal elder abuse. You do a geriatric depression scale and find your elderly Parkinson’ client is depressed. Your psychosocial intervention may be to make an appointment with his physician and have him evaluated and to identify some activities he could take place in that would increase his quality of life and decrease his depression.