My days are varied and unique depending on the specific needs of my clients. There is no such thing as a typical day.

Here are just a few of the things I have done in the past week…

–Facilitate a complex discharge from rehab for a 95-year old client who had a stroke and was returning home. Transitions between care levels are often a time when errors are common. I devote a lot of time to managing and problem solving transitions in care to make sure everything is covered. For this particular case:

• A specialized wheelchair needed to be ordered. When it was delivered, it was not exactly right and adjustments were needed.
• I made sure there was enough medication until she could see her doctor in the community. Sometimes people are sent home with inadequate supply or without a way to get a new RX from the pharmacy.
• The visiting nurse did not come within two days of discharge, so after making some phone calls I found out they never got the referral from the rehab facility. I made sure the orders got faxed and the visit was scheduled the next day.

–I attended a care plan meeting at an assisted living facility to review an increase in cost for a client. Families sometimes do not factor in a decline in function and increase in care level when planning financially for assisted living costs. We needed more information to understand this cost increase.

–I attended a medical visit with a client who has dementia to ensure the physician had all the relevant details necessary to address the medical issues going on with the patient. After the visit, I made sure that new orders were communicated with caregivers and there was follow-through.

–A client at home had a caregiver taking time off, so I introduced and oriented the covering caregiver to the client’s unique needs.

–I had a consultation with a family faced with very limited finances and helped them understand what programs are available and how to apply to help pay for care. And learn what to do if funds run out and care is needed.

The key to effective care management is flexibility and preparation. I am the advocate and voice for my clients and seek to improve their quality of life wherever and whenever possible.

by Joan Garbow, MSW, LCSW, CCM
Advanced Member of The Aging Life Care Association