Care Planning is the process of determining the specific objectives, goals and actions that will enable us to meet the elder's needs as recognized during the needs assessment (click on Needs Assessment). This means identifying the services and supports that are best for the elder and ensuring that their frequency and duration will conform to what the person can afford. It may involve determining the elder's eligibility for public programs. For home health care, this might involve planning within the elder's insurance and limitation guidelines (for skilled nursing care) and it may also involve finding ways of extending the elder's custodial care (personal care, help with meal preparation) through paid caregivers and programs such as Meals on Wheels. If the family needs respite but cannot afford enough home care, the care plan might include such alternatives as attendance at a Senior Center or an Adult Day Health Program. For elders without family support or enough money for private caregivers, the care manager may identify public programs such as In Home Support Services that may pay for some household help and personal care.
When the care plan has been developed and agreed upon by the elder and family, the care manager will implement the plan. Implementation is the process of taking the specific actions or interventions that are required to accomplish the goals outlined in the care plan. This may involve empowering the elder and family to find their way through the health care and social services systems in order to get necessary services. It may also include assisting the elder in completing the necessary paperwork to be eligible for certain services and coordinating the person's transportation and intake interview with the service agency.
Coordination is the process of organizing, securing, integrating or modifying resources in order to achieve the goals of the care plan. In a situation where the elder has many chronic or complex illnesses but not much social support, the care manager may be the person who ensures that the elder gets to her doctor appointments and the person who coordinates with different doctors so that each knows what the other is doing for the client. The care manager may also assist the elder in applying for financial assistance for the cost of prescription medications, ensure that prescription refills are ordered and delivered on time, and monitor the elder's progress and Medi-Set box to see that she is taking medications as prescribed.
Because each person's needs are different, each care plan is completely unique. Call us to talk about your needs today at 650-991-5141.