Geriatric Care Management – John’s Story

Geriatric Care Management – A Practical Example

John is a 79 year old gentleman who had suffered for many years with diabetes, depression and congestive heart failure. When Ivory House became involved, it was because John had been hospitalized due to a heart problem. While in the hospital, the geriatric care manager from Ivory House was called to do an assessment of John’s problems and develop a plan of care for his discharge to home.

While John was still in the hospital, the care manager helped him prepare and write questions for the doctor concerning his condition and prognosis.  She also reviewed John’s chart and spoke with the physician regarding the plans for John’s discharge.

During one hospital visit by the care manager, John was complaining that it was late in the afternoon and he had not had a bath.  The care manager (a nurse) bathed John and changed his bed so that he would feel refreshed.

Assisted Living Care

When John went home from the hospital, the care manager arranged for an aide to assist him with his daily bath.  In addition, the care manager served as a liaison to coordinate care with the skilled nursing, occupational, and physical therapy services which were provided through Medicare.  He lived in a communal assisted living setting so his meals, laundry and other necessities were handled by the community staff.  Because John was anxious about medication management, the care manager prepared his medications in a weekly medication box.

The care manager visited John on a twice weekly basis and more often if the need arose.

She routinely evaluated him for cardiac problems, calling his cardiologist when she had questions about his cardiac status. The care manager also took John to all his physician appointments and assisted John in understanding changes in his condition and medications. The cardiologist gave the care manager permission to increase John’s diuretic for his congestive heart failure based on her observations and within certain dosage limitations. She instituted a plan of care for John to follow concerning his cardiac and diabetes status. John called the care manager when he was not feeling well and she would visit his home to assess him.

Liaison Between Patients and Doctors

Due to John’s serious chronic cardiac illness, the care manager’s assessment would sometimes indicate that John needed to go to the emergency room.  When this happened, she took him there and would stay with him to serve as a liaison to the emergency room physicians and nurses. If he needed to be admitted, she would assist him in answering the questions of the admitting physician and nurse.  The care manager would then visit him daily while he was in the hospital.

Eventually John required a facility that was able to provide a higher level of care. The care manager completed all the necessary paper work and wrote a transfer summary, including all the care she had provided for John.  In addition, she assisted him in the packing of his belongings.

John was most appreciative of all the work the care manager had done for him and John’s quality of life was greatly enhanced by the relationship he had with his care manager.  He continued to keep in touch with her until his death last year.