GERIATRIC CARE MANAGEMENT

www.infinitycare.org

Linda Recinos, RN, BSN, GCMOwner & President, Infinity Care Management

Serving the Greater Lynchburg, VA Community and the surrounding

Counties of Amherst,

Appomattox, Bedford, & Campbell

CurrentSituation

• America is graying and graying fast. By 2030, 1 of 5 people in the U.S. will be over the age of 65.

• Elders are living longer and as they age, they need increased assistance – 50% of those over 85 need support and assistance.

• About 40 million Americans provide unpaid family care to someone over the age of 50 (1 out of 6 Americans is involved in providing care).

Source: MetLife Caregiver Study

The Geriatric Care Manager

Linda Recinos, RN, BSN

The Geriatric Care Manager (GCM) is focused on maintaining the well-being, independence and dignity of elders and dependent adults, while balancing the special needs and problems of families caring for them. Linda is a GCM and a registered nurse with 24 years of experience with 19 of those years specializing in geriatric patient care!

Geriatric Care Manager Nurses can provide…• Objective assessments & care planning• Screen/Arrange/Supervise in-home care • Skilled nursing care; injections, dressings, blood

pressure monitoring, disease mgmt education• A single point of access to the range of eldercare

options• Medication management & teaching• Liaison service for families at a distance• Consumer education, advocacy, and promotion of

independence• Time and money saving expertise• Nutrition & diet compliance education & support

GCMs Positively Impact Quality of life…

UNDERSTANDING: Assessment

PLANNING: Customized Plan of Care

On-Going Re-Assessment

MANAGING Part I: Implementing Needed Services

MANAGING Part II: Follow-up/Monitoring

A PROFESSIONAL PROCESS:With a focus on understanding

Who are Infinity Care Management Clients?

OLDER ADULTS AND ADULTS WITH SPECIAL NEEDS• Adults who could benefit from professional oversight and care• Family members who could benefit from support and guidance• Older adults who want to remain living in their own homes• Dependent Adults whose spouse needs a break• Developmentally Disabled Adults • Psychiatrically Impaired Adults

Case Study

Client Example 76 yearsAlzheimer's Disease (chronic condition)Lives at homeHusband, 78 years old3 adult children living at a distance

PROFILE:

SITUATION:• Miserable experience with paid caregivers in past• Husband increasingly overwhelmed• Each child is getting conflicting information • Ambivalence around placement - feels “guilty”• Needs help and guidance but reluctant to ask• Increased social isolation• Adequate finances & LTC insurance covers care needs• Medication compliance is fragmented: schedule is

difficult to follow• Everyone feels stuck

Interventions

• Initial assessment & consultation with nurse GCM• Conference call with all children and parents outlining

needs, preferences, and cost-effective options• Secured commitment of all involved in process to the

customized plan of care • Initiated intermittent in-home care for the client as a

means of respite -- matched caregiver and set up monitoring schedule via home visits

• Day Care = socialization for wife / respite for husband• Medication device in place; nurse filling it every week• Set up a means for regular communication for family

members

Results

• The client is getting the care & support she needs• Husband can be a partner again; he takes daily walks &

sees some of his old friends for breakfast 1x week• Nurse GCM addresses any problems resulting from

having care in the home – relief for husband• Nurse GCM overseeing meds & orders refills on time;

client gets correct meds every day – husband relieved• As situation progresses, greater peace of mind for all

that there is a professional advocate that will stand by them to help them through the process

CARE MANAGEMENT:A Distinctive model

• Proactive approach• Professionally led decision-

making• Recommendations reflect

balance of assessed needs with values and preferences

• “Whole family” / “whole person” approach

• Improved communication with all involved

When to Call a Nurse GCM?

• Family is out of town and/or only limited social support is available to the client

• Need support and resources to maintain independence

• Caregiver(s) overwhelmed/stressed out• Multiple diagnoses/difficult situations, complicated

decision-making and care coordination• Patient and/or involved family need a ‘road map’

after new diagnosis or hospitalization• Family facing nursing home decision but feeling

guilty and wants other alternative• Client high risk for falls, ER visits, or med errors

When to Call a PGCM? (cont’d)

• Family members disagree about next step; need information and objectivity

• Struggling with balancing safety and independence

• Needing consistent unbiased, accurate communications

• Existing caregivers require supervision and ongoing training

• Non-compliant behaviors with meds or diet• Driving incompetency present; driving risk

When to Call a PGCM? (cont’d)

• Lives alone & has balance or cognitive issues• Main caregiver going on vacation or out of town• No longer able to self-inject insulin or needs

regular allergy or vitamin B-12 injections• Client is vulnerable to elder fraud or has been a

victim already• Poor appetite, malnutrition, irregular meals or

unplanned weight loss• Social isolation or depression symptoms present• Clutter & junk accummulation has become a fire

hazard or falls risk

Infinity Care Management of Virginia provides a variety of services in addition to unique & helpful products to assist senior adults to age gracefully in their own homes for as long as they wish while maintaining their safety, well-being, and independence.

Services that Help Keep Senior Adults Living at Home

Over 10 different kinds of assessments Computerized Medication Dispenser Rentals Emergency Help System with 2-way Voice Communication TeleCare Phone Outreach Service Mental Status Screenings Home management; Bill paying, home repairs, groceries

“TeleCare” is a phone outreach service for patients who need a little monitoring to make sure everything is going smoothly with them. The client is called on designated days and are asked 10 key questions about how they are getting along for that day. The client's answers to those questions determine if there are any "yellow or red flags" present that could be a potential harm or negative consequence to them. The "yellow or red flag" information is then scrutinized a little more in order to determine if a home visit is needed for further investigation. The designated family member is then notified with all information.

TeleCare Phone Outreach Services

• Proactive calls can help ward off a crisis, ER visit, or a hospitalization• Proactive calls are less costly, less disruptive and easier than reactive

interventions• Ideal for clients with cognitive deficits, memory loss, or beginning

Alzheimer's• Can be used as stand alone service or with other services• Available 1 day/week to 7 days/week or as requested

The Emergency Help System or “EHS” is a personal emergency response system with 2-way voice communication that makes live help just the push of a button away. Installation of the unit base will connect your parent or loved one to a "live person" at the emergency response center by pushing a single “ help” button on the main transmitter unit. In addition there is the remote “help” button that is carried with them on their belt, pocket, on a chain around their neck, or on their wrist for that 24/7 availability of help. This life saving unit is rented monthly and is connected to the patient's telephone system for continuous peace of mind service.

Emergency Help System with 2-way Voice Unit

• Ideal for clients with a history of falls or unstable balance• Great for clients who live alone and have minimal support help• Quick response time to local emergency services; police, fire,

paramedics• Low monthly rate plus installation fee

The Computerized Medication Dispenser “CMD” is a safe, convenient and automated solution that organizes, reminds and dispenses medications so pills are taken properly and on-time. The event reporting features make it a true cutting edge device that improves medication adherence and reduces the risk of missed and dosing errors. Reports are immediately generated to the family and/or the nurse so phone follow up can determine if a home visit is needed to take care of an issue. This unit can be installed and rented monthly with the services of the nurse filling the medications regularly or with the family filling the unit with medications for the patient instead. Nursing management services in conjunction with this CMD rental, provide a complete stress-free and hassle-free experience for your parent giving you peace of mind that their medications are under good control..

Computerized Medication Device - CMD

• Visual AND sound alarms alert client when to take medications• Supports independent living for clients who get easily confused or

overwhelmed• Increases medication compliance immediately

Please visit the Infinity Care Management website and click on the “Services” page as well as the “Additional Services” page for more information on how

to make your senior loved one safe and happy at home.

What Can I Do to Get Started?

OR CALL TODAY

(434) 237-1975

www.infinitycare.org