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Senior Citizen's Guide to Pittsburgh

Geriatric Care Coordination
Staying Independent at Home with Help

It seems that life provides us with another lesson in the importance of planning ahead every day. While many of these lessons concern benign instances, like making a reservation in advance at a popular restaurant, there are times when matters are much more serious.

Here's one. As an older adult, have you made plans to help manage your own care when it becomes challenging to manage on your own?

You may not be ready just yet for a caregiver a person, either paid or voluntary, who assists with the activities of daily living and provides companionship. There is another option one with the purpose of managing your overall health and wellness as you age: geriatric care coordination.

The goal of geriatric care coordination (also referred to as geriatric care management) is to help older adults and their families understand, access, and coordinate the resources available to live safe and fulfilling lives. Care coordinators assess needs, develop a care plan, arrange for necessary services, and monitor progress and changes.

Often a family member takes on this role by default; however, adult children often are busy managing care for their own children and families, household tasks, and demanding careers. Or maybe they live out of town and are unable to provide hands-on assistance. Long-distance family caregiving is extremely difficult to manage, as anyone who has tried this knows. With consistent difficulties in navigating the plethora of services and benefits, this is one instance where it can help to call in the experts.

Highly-regarded care coordination programs offer services typically provided by experienced, licensed clinical social workers specializing in geriatrics. Care coordination costs vary. Some programs provide continual monitoring of an older adult and charge a comprehensive, flat-rate, monthly fee. Other programs charge by the hour or a lump sum for a particular service. Although health insurance does not typically cover care coordination, some long-term care policies may.

Comprehensive care coordination programs often begin with an in-home evaluation to review all aspects of life including general health and physical abilities; medical treatments, providers and medications; mood and cognitive status; nutrition; home safety; and current benefits and relevant legal documents. This face-to-face process of questions, answers, and observations provides the care coordinator with a real-time profile of an older adult's strengths and limitations in his or her environment.

With that information, the care coordinator develops and implements an individualized care plan not only to maintain independence but also to enhance the older adult's functional, cognitive, and emotional well-being. As part of a comprehensive program, the care coordinator updates that plan with recommended interventions, or changes in services, monthly.

Depending on the needs of the older adult, the care plan may include any of the following:

The best time to start a care coordination program is before a crisis occurs. When there is time to develop a trusted relationship between you, your family, and the care coordinator, the professional can intervene more effectively if the need arises.

Research shows that hiring a professional care coordinator leads to decreased stress on families juggling multiple priorities. You might also find that it's easier to share issues of concern with your care coordinator than your own family members.

I wish for my children that peace of mind when I begin to meet the challenge of aging with dignity, comfort, and maximum independence. I recommend professional geriatric care coordination to many older adults and their families. When you find a program and care coordinator you trust, objectivity, expertise and compassion are included with the services. That's a plan that's worth making.

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