Whole Family Approach to Geriatric Care Management

An older man who takes medication to thin his blood to prevent a future stroke is hospitalized for an unrelated condition. Because the doctors in the hospital don't know what the usual dose of his blood thinning medication was before the hospitalization and they do not contact the spouse to find out the pre-admission dose, they inadvertently changed the dose and sent him home. The new dose turns out to be twice as potent as his usual dose and within two days he is rehospitalized with uncontrollable bleeding.  A Geriatric Care Manager (GCM) is called to help navigate through the crisis.  The family is in emotional turmoil.  Dad can't make family decisions and he is now confused.  

Care for an aging parent causes a family crisis because the rock of support becomes disabled.  A GCM needs to move this aging family through their crisis to a level of maturity as the care manager is the one who sees the parent/spouse in the here and now.  By reorganizing the aging family into a new team with a team leader, GCMs can now advocate for this new team as well as the patient.  GCMs identify this team leader/caregiver/spouse's needs and identifies what it takes to maintain her health and well being.  By using the whole family approach, a GCM uses family to advocate for the needs of the caregiver and older client himself (i.e., finding another family member to help pay for the spouse's respite or finding another family member who can take weekend care so caregiver can spend weekend with spouse). 

The role of a GCM in the hospital is to do routine care management tasks to: educate, assess, advocate, and move the client and family through the hospitalization process.  When an elderly patient is ill, weak, and confused the family visiting this patient in the hospital is often ignored, adding salt on the wound.  Yet they are also being asked to take on high tech medical care decisions at discharge such as bandaging, caring for wounds, and managing care.  

It is up to the GCM to educate the family to talk to physicians and technical staff.  She coaches the family in making a list of questions they'd like to ask the doctor, making it a running list that can be updated each time; she appoint a family spokesperson so only one person is asking the questions; she educates the family to communicate with the entire health team such as the social worker, Charge nurse, technicians drawing labs, etc. 

It is up to the GCM to advocate for the family so they get information they need. The GCM teaches them how to communicate with hospital staff to be respectful; to introduce themselves and shake hands; to ask questions in a grateful tone; to remain calm; to not be adversarial, etc.  

GCMs are the care navigators in this partnership moving a patient through care transitions.  If rehabilitation is ordered, we make sure it happens and on time.  If it doesn't we advocate with discharge planners.  We help the family understand health literacy teaching caregivers how to get, process, and understand basic health information.  Why?  In order to help caregivers make medical decisions for their loved ones, especially when the patient is incompetent due to temporary confusion or dementia.  We prepare the family to be trained as caregivers for discharge.  We help family ask questions and provide coaching to help them understand who in the facility has the answers.  The GCM is the real discharge planner since we get the family caregiver trained to give care when the patient transitions to the next level of care, help get a home care agency, educate family on community services, and assess the home for safety before the patient comes home.  

In the event a big decision is needed and the doctor needs to include the Power of Attorney (POA), a GCM can advocate for a family meeting in the hospital.  The GCM decides who attends (usually the doctor, a key RN, the POA) and helps family make a list of all questions to be addressed.  What is the GCMs job during a family meeting?  To help family members express themselves; keep the meeting on track and focused on the patient's present condition and the next care transition. After the family meeting a GCM may create a care plan at the end, documenting decisions, submitting a copy to the family and a copy to the physician. In the end, a GCM has the entire family as a client, must assess the whole family, and must advocate for the family to help the patient have a successful outcome.  

If you'd like to share your story as a caregiver to an elderly parent/spouse while in the hospital, please use the comments link below.  olga@agooddaughter.com