How to Identify and Plan for a Person's Care Needs

All too often, I receive a call from a family telling me that they hired an agency or someone privately to provide caregiving services for a loved one, only to have things get much worse.

Well-meaning families often see that a senior or person with special needs is struggling, and quickly jump into action in an effort to help, without considering all the facts. Instead of taking time to properly evaluate the person’s abilities, needs, and developing an appropriate care plan; the family hires a caregiver to come in and help. But help with what?

A SAMPLE CASE

Sally is married with 3 children, and just received a promotion at work in a high pressure job.

Sally has been helping out her mother Mrs. Jones, visiting every couple of days, fixing dinner and paying bills.

Over the past several weeks Sally has noticed her mother is more confused, argumentative, anxious, and repeating herself more.

Worried about her mother and believing her mother is developing Dementia, Sally calls a homecare agency, and the agency sends over a caregiver to work four hours a day.

The situation continues to get worse. Why?

- Mrs. Jones has a urinary tract infection (UTI), which is known to cause confusion, anxiety and irritability

- Mrs. Jones isn’t taking her medication as prescribed – sometimes forgetting to take her pills and other times taking too many pills

Each human being is unique, and as a result each person has unique needs. Some people may experience mental and physical limitations that limit their level of functioning, while others will remain relatively high functioning.

Evaluating a person’s care needs is like putting a jigsaw puzzle together. The more pieces of the puzzle you have the clearer the picture.

Care for seniors and people with special needs often requires a multi-disciplinary team approach consisting of a variety of members such as the primary care physician, cardiologist, neurologist, physical therapist, occupational therapist, certified case manager, and caregiver, to name a few.

I often refer to the client’s team as being like an orchestra, with each member having a unique set of skills and talents that they bring to the group. The role of the certified case manager (CCM) is to serve as the conductor of the orchestra; ensuring that there is good communication, teamwork, and that everyone remains focused on the client and family’s goals.

The first step in working with a client is to obtain a comprehensive assessment which depending on the particular client may focus on the client’s:

• Health and Mental Health
• Activities of Daily Living (e.g. dressing, bathing. meal preparation)
• Transportation
• Finances
• Social Opportunities
• Emotional Well Being

Once the client has undergone a comprehensive assessment, the information obtained will be used to outline a care plan (road map) that focuses on the individual’s current needs (e.g. dementia, high blood pressure, unsteady balance and gait), required treatment (e.g. medical, psychiatric, physical therapy), housing requirements (home with assistance, short term rehabilitation), activities of daily living (e.g. bathing, dressing, meal preparation), socialization, and optimal utilization of community resources; to name a few.

It’s important to have the certified case manager and team review and modify a client’s care plan every 60 days, or when there’s been a status change in the client (e.g. fall, heart attack, increased cognitive decline).

Based on the individual client, it may be possible for the individual to remain in their own home with family or paid caregivers, or they may need to look at alternative housing, such as an assisted living facility or nursing home. It’s important to continually monitor the client, and as their needs change, the care plan will need to be modified to address their evolving needs.

If it’s determined that the client would like to remain in their home with help, and this is an appropriate option, then the next step is to determine how best to select and hire a caregiver.

AVAILABLE OPTIONS MAY INCLUDE

1. Independent Contractor

2. Registry

3. Home Care Agency

- Medical

- Non-Medical

REMEMBER

Before any caregiver is hired it’s important to follow these steps:

• Have a professional assess the client’s needs

• Identify the client’s abilities, needs and wishes

• Develop a plan to address each of the client’s needs

• If it’s determined that a caregiver is needed, be sure to select a caregiver that has the skills, knowledge and experience to help address the client’s unique needs.

• Do your homework in researching and selecting an agency and caregiver.

Photo from Microsoft

The information in this article is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information is not intended to be patient education, does not create any patient provider relationship, and should not be used as a substitute for professional diagnosis and treatment.

Please consult your health care provider for an appointment, before making any healthcare decisions or for guidance about a specific medical condition.

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Linda Ziac is the owner and founder of The Caregiver Resource Center. Linda founded her company in October 1990, and provides concierge case management and advocacy services for seniors, people with special needs and families.

Linda’s professional career spans 39 years in the health and mental health field as a CT Licensed Professional Counselor, CT Licensed Alcohol and Drug Counselor, Board Certified Case Manager, and Board Certified Dementia Practitioner.

Linda’s role is to work with the client, their family and healthcare professionals to help assess, plan for and implement ways to allow for their greatest degree of health, safety, independence, and quality of life. We are often asked to help when a person is taken to the ER, is in the hospital, or there is a need to help assess and implement a plan to address a person’s day to day needs.

This process involves identifying a client’s abilities and needs, and helping to design a care plan (road map) that is composed of a spectrum of services, that best meets the unique needs of that particular client. A client and their family select the services that they want, and they only pay for those services.

http://www.CaregiverResourceCenter.com