The Case for Care Management in Home Care
Broad Street Solutions in Senior Care:
“One size does not fit all”
THE HOME CARE CHALLENGE:
When people reach out for Home Care, they often have very specific needs. While there could be underlying health conditions that need support, there is also an individual’s unique way of life and daily routine that need to be considered. Unfortunately, traditional Home Care is not equipped for this level of detail.
While it’s possible for Home Care to support a variety of scenarios, the approach often comes down to simply staffing a Caregiver. It is the Caregiver themselves, with often limited instruction or direct support, who must adapt to the situation. This can result in the following:
A lack of preparation or client specific training
Inconsistency among Caregivers
Poor communication
While having a great Caregiver is essential in getting the right support, this “one size fits all” approach can lead to frustration for everyone, including the Caregiver. However, having Care Managers involved can make the difference in getting the right Care Solution in place.
THE HOME CARE SOLUTION:
Care Management is a term applied to a large variety of services provided by professionals from a number of different backgrounds. Care Managers can provide organizational and administrative support including helping manage vendors and finances. But it can also focus more on healthcare, ranging from deep clinical support including Patient Advocacy, to serving as an intermediary between family and other individuals or organizations in a support network.
How Does Care Management Relate to Home Care?
As it relates to Home Care, we want to focus on how certain specific capabilities within Care Management can support a Client’s Home Care Solution. These can apply individually, or collectively, as Care Management really is the Customization behind Home Care. Specific services may include the following:
Assessing underlying Health Conditions and Clinical Home Care Need
Developing a more Comprehensive and Customized Plan of Service for Home Care
Providing more detailed Client-Specific Training and Instruction to Care Professionals or Private Nurses
Medication Management (Care Managers who are also Private Nurses)
Create Greater Consistency in the Quality of Home Care
Greater Connectivity to Healthcare Network (Bridge between Health and Home Care)
Liaison to Client, Family and the Care Professional and Private Nurses providing support
Support during times of Critical Need (Patient Advocacy)
Integrating into an Overall Home Care or Home Nursing Solution
Better Assessments of Underlying Health Conditions and Clinical Home Care Needs
Care Managers often have backgrounds in Nursing or other clinical fields within healthcare. This experience allows Care Managers to assess the underlying health conditions of their clients and how to support them. Care Managers can do this in collaboration with their clients’ healthcare professionals to make ensure that the Home Care support is incorporating any prescribed treatment plans including medication, nutrition, or exercise regimens. This allows the Care Manager to also determine what skills and experienced are required from Caregivers or Care Professionals to support their clients’ underlying health conditions and related symptoms, whether they are physical, cognitive or both.
This is where a Care Manager’s experience is crucial…
Care Managers, coming from nursing backgrounds, not only have clinical knowledge but they have a practical knowledge of what is required to provide the support. They know how to provide that support directly, and they know how to train people to do it. Furthermore, they understand the cause and effect to better assess if something is working, and if not, they can adjust the support and/or collaborate with the clients’ healthcare network to reassess the situation.
Developing a More Comprehensive and Customized Plan of Service for Home Care
After meeting with client, whether in their home or in a community, Care Managers can help develop a more detailed Plan of Service. Traditional Home Care may create a checklist of tasks that need to be completed which they will effectively hand over to the Caregivers. The details of how that support is delivered is determined largely by the Caregiver and the Client, and hopefully they agree.
With Care Managers, they not only incorporate the support of any underlying health conditions, but they can work through the details that go beyond basic needs and encourage daily living and quality of life.
This more detailed and Customized Plan of Service can be used as a guideline for both the Caregiver or Care Professional, as well as the Client and their family. Care Managers can continue to monitor the effectiveness of the plan and adjust and adapt based on what is working and any changes in the condition.
Providing More Detailed Client Specific Training and Instruction to Care Professionals or Private Nurses
While the Customized Plan of Service provides the guidelines for support, it is the specific instruction that brings the Plan of Service to life, and ensures it is being done properly and consistently. Once again, Care Managers coming from clinical and often Nursing backgrounds understand this process. They are typically experts in providing the direct support and have worked with Caregivers and Care Professionals in and out of clinical settings to explain the right support.
The difference with Care Managers is that they also understand the big picture. It is not just about providing clinical support but putting into the context of daily life and personal preferences. While there may be underlying health conditions which need to be managed, ideally it can be done while supporting quality of life. And in many ways, by supporting quality of life, the body and mind can help in managing the underlying health conditions.
Medication Management: Care Managers Who Are Also Private Nurses
Medication is often integral to any Home Care Support Plan, however, it is often the case that different physicians can prescribe a variety of medications for a variety of conditions, and it is the combination of these medications that can create complications. While Physicians should review the overall medication list, Care Managers can help by reviewing these prescriptions and asking the right questions with the physicians based on a better understanding of their client’s symptoms and daily routine.
But it is after the Medication Plan is consolidated, that the actual Medication Management becomes so important, if not more important, as it is often how the meds are taken that determine their effectiveness or to avoid complications. Taking medications on time, managing a diet that doesn’t inhibit absorption, understanding side effects are just some of the considerations that need to be taken into account. This can make the difference between medication working effectively or in the worst-case causing harm.
Furthermore, proper Medication Management helps determine whether the medication is effective at its current dosage. If not taken correctly, it can lead to unnecessary or even harmful adjustments that work against the desired outcome.
Creating Greater Consistency in the Quality of Home Care
It is not uncommon, in fact it is expected, that the type and level of care will change over time. However, sometimes this care can drift or even regress. It is often natural to fall into a path of least resistance and even lethargy. This is where Care Management can help keep the Plan of Service from failing ineffective. By proactively managing the Care and adjusting and adapting it to changing conditions Care Professionals and Nurses can then support quality of life and daily routine.
It is also common to have more than one Caregiver or Care Professional working with a client. It is important that everyone is following the same general plan. This does not mean that individual Caregivers and Care Professionals need to have the exact same styles and approaches. In fact, it is the collaboration between Care Managers and Caregivers and care Professionals, along with Clients, that can help the Plan of Service and the overall Care to evolve.
By embracing the practical experience and incorporating it into any support of underlying health conditions, the Care Manager can help optimize the Care and the overall experience.
The Bridge Between Health and Home Care: Greater Connectivity to Healthcare Network
A Care Manager’s clinical experience combined with their active knowledge of how Care is being delivered in the Home, creates a natural bridge from a client’s Healthcare Network and their daily routine in their home.
This starts with connecting with the Healthcare Network, including Physicians, Therapists, and other clinicians along with consolidating medical history, treatment plans and medication lists, and then incorporating that into a daily routine and instruction for the Client and any Home Care Professionals and Family.
With that foundation in place, and by incorporating and relevant treatment plans into a Home Care Plan of Service, a Care Manager can then periodically evaluate how effective the Home Care support and treatment plans are in achieving the desired health outcomes. Equipped with this practical awareness and the clinical knowledge, Care Managers can then attend and support doctor’s appointments and help in communicating this vital information. This result is a much more constructive and productive visit where the Clinician can make much more informed decisions.
Ultimately the Care Manager helps consolidate all the valuable time and insight that occurs on a daily basis so that it can be condensed into the more clinically concentrated time with Healthcare providers. The result is more effective management of underlying health conditions while allowing the client to continue to enjoy their life.
Care Manager’s Role: Liaison to Client, Family, and the Care Professionals and Private Nurses Providing Support
The relationship between the Client and their Family and the individuals providing direct support is arguably the most important element in successful Home Care. It requires deep knowledge and understanding of the underlying health conditions and how to respectfully provide support, but if successful, it ultimately leads to trust and mutual respect. This can take time, and often there can be anxiety and stress working through some of the challenges inherent in such an important and interdependent relationship.
Care Managers can perform a vital role in helping this relationship start off on the right foot, and then to help maintain that relationship as everyone moves up the learning curve, and through patience and understanding it adjusts and adapts, building towards that vital trust and mutual respect.
Care Managers Act as a Bridge
They can gather feedback from the Client and Family, as well as the Care Providers and translate it back in a constructive manner. They can make changes to the Plan of Service and provide further instruction to the Care Professionals and Private Nurses. By being a liaison, it reduces the risk of things being taken personally, or being misinterpreted. Furthermore, the Care Manager can proactively communicate, to make sure everyone is aware of everything they need to be, and to avoid potential sources of conflict. Sometimes just being aware of issues in a timely manner can avoid small issues from turning into major issues.
Ultimately the Care Manager’s role as a liaison can be effective because they are aligned with everyone’s interest and the goal of Home Care: To provide the best possible support while fostering deep relationships based on trust and mutual respect, so that the support has the flexibility to adjust and adapt to changing conditions.
The result: Great outcomes for both underlying health and quality of life.
Patient Advocacy Offers Support During Times of Critical Need
While Care Management can mean a lot of different things, Patient Advocacy is more specific to a client’s interaction and navigation through the Healthcare system. It is not only complementary to Home Care, but in many cases, it is a necessary and vital to an overall solution. Care Managers with clinical backgrounds better understand how the system works, and as alluded to earlier, can be a bridge to the healthcare system.
This is particularly important in times of potential critical need. In the case of a hospitalization, having a Patient Advocate who has insight into the cause of the hospitalization along with the additional context of understanding medical history, can be vital in helping physicians with the necessary information to troubleshoot the situation. Care Managers, servings as Patient Advocates, can also help ensure the right care is being provided in Hospitals or Skilled Nursing or Rehab Facilities. With the strain on our healthcare system, medical error is now the leading cause of accidental death, exceeding all other accidental deaths combined.
Patient Advocates can work with these overburdened facilities to not only mitigate that risk but to ensure that their clients are getting the appropriate level of attention.
In addition to helping manage the critical situation, Care Managers as Patient Advocates, can then work with clients as they move through the continuum of care from Hospital to Rehab and eventually discharge to Home where rehabilitation can continue seamlessly into the Home Care Plan of Service. The goal is to get through the critical need as safely and effectively as possible, so clients can get back to their daily routine and the enjoyment of life.
Integrating into an Overall Home Care or Home Nursing Solution
The role of Care Manager in Home Care is to be a solutions provider. With a clinical background and experience, Care Managers can understand not only your underlying health conditions but how it uniquely impacts their clients. Furthermore, it is about having the practical knowledge on how to specifically support those needs, develop a Plan of Service that outlines that support and then training and instruction to put that plan into action and adjust and adapt until it is working effectively for everyone.
And then it goes beyond the Direct Home Care Service or Private Nursing, where it involves creating a bridge to the Healthcare Network and being a Patient Advocate.
Both as a means of proactively supporting underlying health conditions and symptoms to avoid healthcare emergencies, but also to directly serve as an Advocate in cases of Hospitalization or other critical healthcare needs.
A Care Manager is there to help establish clients’ support structure and then fill in the gaps when and where needed as part of a true Home Care Solution.
BROAD STREET’S SOLUTION:
At Broad Street, Care Managers are directly involved in each of our client cases, whether Direct Home Care, Private Nursing or both. With backgrounds in Nursing and Physical Therapy, they work collaboratively with our Care Professionals and Private Nurses.
Our Care Managers also serve as Patient Advocates, both as part of our Direct Home Care and Home Nursing services, as well as independently. And while we specialize in supporting complex underlying health conditions, our service model and capabilities are really designed around individual clients’ needs and preferences as part of a Customize Home Care Solution.
If you have any questions about Care Management or Patient Advocacy and how that can be incorporated into a Home Care Solution or anything else related to Home Care or Home Nursing, please don’t hesitate to call us. We are here to help you find the Home Care Solution that works for you. Please contact Broad Street today.
Broad Street Solutions in Senior Care
Home Care is all about people, probably more than any other service that exists. It is filled with complexities and uncertainties, because every human being is different. But if we embrace that fact, we can then redirect our focus and approach every situation and every person uniquely. Because we know that within all of that complexity lies the potential for great relationships, relationships based on genuine care.
At Broad Street, we spend the time to understand the details, to prioritize the needs and attributes as well as work through the challenges and constraints. It is through this process that we continue to learn and adapt. Life is inherently unpredictable. But with greater understanding, we can better anticipate and manage towards not only a solution but towards creating a great and fulfilling experience for everyone involved.