To create a care plan’s interventions to client’s problems you need a continuum of care. How do you find this continuum? As a geriatric care manager or aging professional, you should already have significant experience in this continuum before you open your door for business. A core competence to open a geriatric care management business or any other aging related business is to know your need to know your community’s continuum of care from day one.
As your care plan or the safety net you build or expand around your client web billows, expands, compresses, and changes constantly, you need the real Web to help you keep up. You can access most areas of the continuum of care and all its changes (new businesses, new senior services offered in part through the Internet. You can access your county’s or Area Agency on Aging Web site, which will usually list all the current senior services available in your town. Almost every county in the US has an area agency on aging and most have a web site that lists all the services available to seniors by category, such as nursing home, assisted living, home care agency, support groups, senior transportation etc.
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 combine assessments? Let’s again take a caregiver assessment and functional assessment. In your functional assessment you have found the older client has a self-care deficit. They have a family caregiver yet their clothes are dirty and they are not being bathed on a regular basis. When you do your caregiver assessment you find that the family caregiver, the aging spouse, is not only depressed but also burnt out. They have been caring for the husband for 7 months are exhausted and skipped critical care giving tasks. Adult children are aware of this and called you, the geriatric care manager or aging professional, to do a geriatric assessment. You can list both older client self-care deficit, caregiver burnout and need for informal support (the adult children) as problems in your care plan. You can also list need for formal support –(a caregiver support group, a private duty home care agency) as a problems in your care plan. You are calling attention multiple main problems – why they need a caregiver, the problems with the caregiver and extended family in a brief, through, and connected list in your care plan. This is just what you need in a care plan under problems. You have derived the problems from two separate assessments yet connected them in the care plan.