Rona Bartelstone Care Management and Home Healthcare

The following are some ideas that eldercare professionals recommend to prepare for and minimize the effects of financial and health crises:

The family had previously used our services for his late wife. They felt that their dad now needed a Care Manager to help him get through this sad, tough time. He was alone, his money was running out, and he was getting depressed.

Our Care Manager met with Mr. Win and did her comprehensive professional assessment to determine his needs. He and his family were advised to go to an elder law attorney for help with legal planning in the event that he outlives his resources. Mr. Win’s attorney and accountant offered advice that provided him and his family with peace of mind about his finances.

During the professional assessment, the Care Manager learned about the extensive medications that Mr. Win takes, and that although he has Medicare part D to help pay for prescriptions, he was buying everything at his local pharmacy. She informed Mr. Win that he could save a great deal of money each month by using the plan’s mail service. He was initially reluctant to make a change because he had known the pharmacist for 25 years and did not want to take his business away. However, after a dollar-for-dollar comparison of the price difference, Mr. Win felt compelled to make the change. To limit his sadness about changing this provider, the Care Manager reminded him that he could still shop at his local pharmacy for all of his non-prescription and toiletry needs. This action prevented Mr. Win from stopping some of his expensive but very necessary medications. The Care Manager saved him over $400.00 per month.

Another benefit was the Care Manager got him a credit card to pay for the prescriptions and use at the pharmacy, which would give him frequent flyer miles that he didn�t have before. Now he can actually afford to visit his great-grandchildren in other states once in a while, and what a great legacy that is!

He was a real “Win-ner” and so was his family. The Care Manager had done her job, which was rewarding for her, too. The Win family found out that with the right guidance, just about any problem can be solved.

A Tale of Two Patients
It was the best of transitions; it was the worst of transitions.

Mrs. Ellsworth

Mrs. Ellsworth is 86 and lives alone in Florida. Her only living relative, a niece, Becky, lives in New York. As far as Becky was concerned, her aunt was doing fine, living in an independent living community. Then came the call that Mrs. E had been hospitalized, having fallen in her apartment and found a day later, seriously dehydrated with multiple abrasions that needed wound care. Her aunt had a history of hypertension, some thyroid problems, and had now been diagnosed with congestive heart failure. In the hospital, she was somewhat confused, but it was assumed that this was secondary to all she had been through lately. The plan was to discharge her with home healthcare from a certified Medicare agency. They would provide a nursing visit for the wound care, and some home health aide services for shopping and bathing a few hours a week for several weeks. As she had been independent prior to hospitalization, this seemed like a reasonable plan. Mrs. E was sent home on a Friday, and the nurse came Sunday afternoon, only to find her in her hospital gown, dehydrated, with no food in the house, and delirious from a UTI. Mrs. E returned to the ER and was readmitted. During that hospitalization, she got an infection requiring another 5-day stay and ultimately a transition for one month to sub acute rehab, and was then discharged with 24-hour home care.

Mrs. Thompson

Mrs. Thompson, 83, lives in Boston. Her daughter lives an hour away and has a high-powered, demanding job. Mrs. T was diabetic and noncompliant with diet. Her blood sugar skyrocketed; she became dehydrated, lethargic, and had to be hospitalized. They were able to bring all her numbers under control in the hospital, and provided nutritional counseling. She was discharged, and the discharge planner arranged nursing visits from a Medicare-certified home care company a few hours a week for several weeks to make sure she was following her discharge regimen. The daughter thought that it would take more to be sure that her mother really would follow the recommendations and called SeniorBridge. Our nurse reviewed the recommendations and took the patient home. When they arrived, another member of the SB care management team was already there, reviewing meds and food, isolating the cookies, candy, and high-sodium foods and shopping for food based on nutritional recommendations. Mrs. T was introduced to a caregiver who had been oriented to all her needs. Soiled linens had been changed, the apartment was ready, and meals were healthy and freshly prepared. The SB caregiver came initially for 6 hours a day to ensure she was following her diet and eating properly. The Medicare agency’s caregiver provided 2 hours of assistance 3 times a week for grocery shopping. SeniorBridge’s services were wrapped around the Medicare agency’s. Mrs. T’s blood sugar remained under control, and after a month, the Medicare caregiver pulled out, but our caregiver remained for 4 hours 5 days a week. Our care manager goes in weekly to check her blood levels and diet, and she is doing great.

It's a far, far better thing we do...


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