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Preventing Re-hospitalization

Posted on 5 January, 2014 at 14:45 Comments comments (456)

Life Journeys, LLC. Registered Nurse Geriatric Care Coordination

Changing the end of the story…

As the aging person experiences episodes of illness or decline, returning to their prior level of functioning becomes increasingly difficult, making loss of independence a continual threat. When our loved ones experience changes in their health that affect their abilities to continue to remain safe and independent, they need a better understanding of the choices they are facing, and how to access the level of care they may now require.

Patient care has come around full circle, from the long hospitalizations of many years ago, to acute short stays focused on getting the patient stabilized quickly, and then transitioning them to a lower level of care, all in the name of saving healthcare costs and maximizing profit.

With these rapid transitions, patients are often moved through the healthcare delivery system without clearly understanding the choices being offered to them. Many times a person’s preferred choice is to continue to living in the familiarity of their own home or the home of their grown children for as long as possible. However, returning home may not be the best option unless there is a capable family member or friend to help plan, coordinate, and follow through with making sure their care needs are truly being met. Unfortunately, many families don’t have a person capable of helping to meet these changing needs.

Any changes in health can trigger a further cascade of problems that need to be addressed quickly while they might still be safely managed, and re-hospitalization can possibly be avoided. By utilizing RN Geriatric Care Coordination to help make a plan, put services in place, and work directly with the client and their family to oversee ongoing care needs. If changes in health occur, they can be managed quickly and more effectively. With improved response to changes in condition, our patients and clients will have the best chance of maintaining their highest level of independent functioning. Other priorities include conserving their assets and resources, preventing re-hospitalization, and improving their chances for long term overall optimum health.

By seeing our patients in their own environment, we can observe them in ways that are not always apparent during an office visit or a typical hospitalization. The family dynamics, as well as their individual lifestyle and health habits are more easily recognized, allowing us to focus our teaching to more specific needs and helping to resolve problems before they become more difficult to manage.

Helping our patients and clients find acceptable choices for changing unhealthy lifestyles is of key importance, making compliance with living healthier and remaining safe and independent at home a more realistic option. The reality of cutting the healthcare costs of this nation depends on our ability to help the aging population find ways to make these healthier lifestyle habits do-able at their level of ability.

Utilizing the services of a Geriatric Care Coordinator to work with families to build a structured plan of care can make these challenges seem more manageable and less overwhelming A viable option for many families might be having a family member or friend who can help, at least on a limited basis, if given directions and a coordinated plan that respects the family’s resources, abilities, strengths, and needs. A coordinated plan that includes additional support from professional medical or non-medical home healthcare agencies can make an overwhelming situation managable.

Ultimately, by remaining safe at home with care needs met, assets and resources can be conserved for long term care needs in the future. We will also be delaying facility care before it is needed, and minimizing or avoiding the need for endowments and long years of government subsidized facility care.

There are times when caring for loved ones at home is not realistic or safe. Sometimes we are even trying to care for our loved ones from another city or state. Consequently, more customized options are being made available for our patients and aging parents. Understanding all of these options can be challenging for healthcare providers as well as the seniors and their families themselves. Utilizing RN Care Coordination also helps families make these difficult life changing decisions by helping to make their transitions smoother and less traumatic.

Supported family involvement, as well as a person’s level of being able to care for their own needs as they decline physically and/or mentally, contributes to determining the direction and level of care needed. Medicare or insurance reimbursement for needed healthcare services can also affect the type care a person receives, and for what period of time.

Our Medicare system managed by CMS (Centers for Medicare & Medicaid Services) is more often than not, the major determining factor in services being received. What does the future hold for a healthcare system that is facing unfathomable changes? The only chance of survival will be cost containment, resource management, and the patient themselves doing their part in adopting healthier lifestyle habits. If individuals do not make those changes, they not only personally suffer the consequences in ill health, but also must pay higher health insurance premiums along with others in their network.

Some of the questions we must ask ourselves as diligent healthcare providers…

• Where will our patients ultimately end up?

• Will they thrive at home?

• Or will they fail because of lack of funds, or lack of coordination of the services they needed to manage their care needs within the safe environment of their own home?

• Will they continue a cycle of returning to the hospital where they started because their care needs are not being adequately met?

• Will the hospitals continue to take them in again and again at the risk of no Medicare insurance reimbursement?

• Will they move on in the continuum of care to a different or higher level of care in the system?

• Will it be where their needs are being appropriately met?

• What does the future hold for supporting our own changing healthcare needs as we ourselves experience aging?


As true patient advocates, it is our responsibility to understand the healthcare choices available to our patients and clients, and to help them access the appropriate level of care within a system that offers choices that are usually confusing and overwhelming, especially at a time when they are likely experiencing life changing circumstances and are vulnerable.

Utilizing RN Care Coordination as part of Care Management teams just makes sense when it comes to quality care expectations and outcomes. Working together for our patients teaches them to maintain accountability for living healthier, helps them to maintain their autonomy longer, and helps to keep runaway healthcare costs more manageable for all of us.


For a free consultation please contact us,


Life Journeys, LLC,

Registered Nurse Geriatric Care Coordination

515-554-5489 [email protected]


Is your loved one safe?

Posted on 30 December, 2013 at 13:25 Comments comments (1066)

If you don’t have an aging parent, you probably know someone who does. Perhaps one of your closest friends is struggling to try and care for their loved one as they go through changes in their health, and trying to meet the needs of the others in their family at the same time.

How do you know when these changes are occurring in your loved one? What do you look for when your parent is telling you that everything is fine, but you see evidence to the contrary? Or maybe you have a gut instinct that is telling you that your parent is bluffing by using humor in odd ways to cover for the beginnings of forgetfulness, or no longer being able to care for their own needs as well as they used to. Maybe you are seeing changes, but you are avoiding confronting the concerns because you don’t know what to do or where to start. After all, this is your parents, we are talking about. They have always been there to help with our needs. They can’t possibly be getting older and frail!

Are they safe to be left alone?

Let’s start with some commonly observed potential areas of risk:


o Are clothing items frequently stained by food?

o Is the person losing weight without an obvious explanation?

o Are they drinking enough water, especially in the Summer? (Urine may be dark and concentrated or they may have a dry mouth. They may complain of dizziness when they stand or a frequent nagging headache)

Preparing food:

o Are food items being kept long past expiration dates?

o Do pots and pans appear to have repeated scald marks?

o Has the stove been found left on?

o Is the client making healthy food choices, or is there mostly cereal, breads, soup, and easy to eat without preparation foods?

o Can your loved one, plan and prepare a balanced meal?

Getting in or out of chair or bed:

o Does the person rock back and forth several times before actually getting up?

o Are nearby furniture items or objects used for support?

o Does sitting seem to involve falling backward into a chair?




o Are clothing items soiled or wet?

o Is there a noticeable odor of urine or improper hygiene?


o Is the person’s hair and skin dirty or oily?

o Is there notable body odor?

Dressing and Grooming:

o Does the person have a rumpled or disheveled appearance?

o Is there inattentiveness to hair, make-up, clean clothing, jewelry, or other things that were once important habits?

o Does it take them an extremely long time to manage getting dressed on their own?

o Do they avoid going out and being with others because it is too hard to get their bra fastened or they can’t put on shoes and socks any more?


o Does the person seem unsteady or have poor balance?

o Have there been reported falls, or the observation of bruising and abrasions?

Taking medications:

o Do prescriptions last longer than they should?

o Are prescription refills being needed prior to the refill date on the bottle?

o Are you finding loose pills in unusual places?

o Can the person read the labels and understand what conditions the medications are actually used to manage?

o Are prescriptions being ordered from more than one pharmacy?

o Or several different doctors?

Using the telephone:

o Does the person seem to understand phone conversations?

o Is the phone not answered when the person is known to be home?

o Can the person demonstrate the ability to call 911 if given a hypothetical safety risk situation?

Home Safety

o Are you finding that your loved one often has the thermostat set way too high or low, especially in the Summer or Winter months?

o Are you noticing changes in their abilities to use the microwave & stove?

o Is a ‘simple style’ tv controls too difficult (Let’s face it, there ARE way too many buttons most tv controls for most people’s needs)

o Are they able to get out of the home safely if there is an emergency?

Managing money, mail, and paying bills:

o Do bills go unpaid, leading to overdue notices or shut off of utilities?

o Has the person been repeatedly notified of overdrafts on accounts?

o Are you noticing a lot of window mail from charities?

o Can the person demonstrate counting the correct amount of change while making a purchase at the store?

o Or do they hand their cash and credit cards to others to count for them?

o Does the person complain about too many telemarketers calling and bothering them?


o Are you noticing bruises and abrasions that your loved one minimizes?

o Are you getting phone calls in the middle of the night to help them get up off of the floor?

Getting lost

o Is your loved one having more difficulty finding their way around inside or outside of their home?

Doing laundry:

o Are clothes clean?

o Is the person wearing the same outfit for more than 2 days in a row?

o Are they unaware when they have spilled food on their clothing?

o Are you seeing socks and underwear hanging in the bathroom, but there doesn’t seem to be much in the laundry basket?

o Is your loved one trying to hand wash disposable incontinence briefs to save money?


o Are pathways clear and clutter free?

o Are there loose throw rugs or cords that create a fall hazard?

o Can the person find things readily when they are needed?

o Do they have so much stuff that they can no longer manage it all?

o Does the word “hoarding” keep coming to your mind when you think of having to manage all of the stuff that is over accumulating?

o Do you feel panicked about not knowing how or where to start helping them?

Using transportation:

o Are they still driving even when you are concerned about their safety?

o Or has the person repeatedly become lost while traveling in ways or on routes that are usually familiar?

o Are you afraid to ride with them yourself for safety reasons?


o Is the kitchen or pantry stocked with a reasonable amount and variety of food items?

o Are the food choices healthy or convenient foods that don’t need preparation?

o Is the person complaining of not being able to sleep at night and watching tv at unusual hours?

o Are you noticing an unusual number of packages being delivered in the mail? (Mostly from QVC and HSN)

o Are they left unopened once they arrive?

o Are they useful or unusual items?

Suspicious or Paranoid behavior:

o Does the person accuse others of stealing things? Things that typically hold no interest for others, or things that are typically found later, maybe in odd places.

o Are they easily offended by remarks of others, comments that would not have bothered them in the past?

o Is the person often defensive or argumentative in their responses?

o Are they trying to convince you & themselves that everything is “just fine” and that they are not having any difficulties with anything?

o Are their responses to you realistic?

o Are they beginning to hoard money or food?

o Are they resistant to help, because they have always managed on their own, and will continue to do so until they absolutely can’t anymore?

So now what?

• Who do you call to help you understand what your choices are once you find yourself spending more time in the emergency room or doctor’s office than seems reasonable?

• Or when you are experiencing repeat hospitalizations?

• When you are getting panicked phone calls in the middle of the night and at work?

• What do you do when taking yet another day off work is putting your job security at risk?

• Who is available to help if your parents live in a different city than you do?

You may be at a crossroads and the choices seem overwhelming and daunting. Partnering with an RN Geriatric Care Manager for a comprehensive assessment of your loved one’s abilities and needs may be the key to helping you know where to start. We can also help to navigate the healthcare delivery system with less stress and a better understanding of your choices. Please call for a free in home consultation for you or your loved one.

Brenda Rose, RN


Life Journey, LLC. Geriatric Care Coordination

Changing the end of the story…