​Vital Living Forum-Developing a Care Plan

A business plan is an essential road map for companies to succeed. It provides insights into a company's strengths, weaknesses, and opportunities. This business plan is a living document that generally projects three to five years ahead and outlines the route a company intends to take to grow and expand.

 

Likewise, it is just as important to create a business plan or care plan to coordinate the needs of a frail elder. Care planning is the process of creating a road map that identifies how the care of a frail elder can be best coordinated to meet their long-term care needs, improve their quality of life, and maintain their independence for as long as possible. In today's Vital Living Forum, we'll explore the different types of elder service professions that exist in Central Florida, how the strengths and needs of an elder can be assessed, and how care services can be coordinated as families work to develop a living, breathing care plan.

 

I'm Katie Dagenais, and let's get started. Joining us for today's shows are Patty Antony and Amy O'Rourke. Patty Antony is a physical therapist with 33 years of experience.

 

She is also a board-certified geriatric clinical specialist, certified aging and play specialist, and a care manager. Patty is the founder and president of Elder Advocates, Inc., a care management company. Amy O'Rourke is a licensed nursing home administrator.

 

She has served on the board of directors for both the National Association of Professional Geriatric Care Managers as well as the Florida Geriatric Care Managers Association. Amy is the founder and president of the Cameron Group, a geriatric care management company. Ladies, thank you very much for joining us today.

 

Thank you. Amy, let's go ahead and get started. Before we start talking about developing a care plan, it's important that we know the different way that elders in the United States are cared for.

 

What are the different ways? There's a variety of ways. There's a concept called continuing care retirement communities where you have three or four levels of living on one campus. You have assisted living facilities which have care for the physical needs of the elder, and then you have skilled nursing facilities, otherwise known as nursing homes, and that cares for the totally dependent elder.

 

You have the daycare concept where an elder can go somewhere for the day and then come home, and then you have home care in which there's four or five different categories of types of caregivers for home care. And is it true that most elders are actually cared for in their home, Patty? That is true. Only about 4% of seniors actually reside in a nursing home, and that number really hasn't changed despite the number of people living way beyond 85.

 

Of course, as you get over 85, the numbers of people residing in a nursing home do increase somewhat, but the majority of seniors, which is considered over 65, live at home. So let's jump right into this. What are some of the different types of services that are available right here in Central Florida? In Central Florida, really in the state of Florida, you can get care from a licensed home care company, and a licensed home care company provides employees who are workers' comp insured and insured as employees that work in the home.

 

The company absorbs all the liability of the care that that person's providing. You get care from a nurse registry. A nurse registry employs what's called 1099s or independent contractors.

 

So those people go into the home, but they are not insured and they are not employees, so the liability is borne by the family. And then people hire friends. They hire people from websites privately.

 

And so those are really the three ways of receiving care in the home, and the fees associated go up with home caregivers typically charging less, and you pay the most if you get it through a home care agency. Now, there are a lot of options. I imagine that gets confusing, especially as you're looking at liability and different options and prices.

 

Right. Home care can be a companion type of person who is just going to help with errand running and not really physical assistance as much as just being there to assist. And then you can have home care that is more skilled, where people have a license or a certification to assist with physical needs in the shower and lifting and some of that type of thing, and the prices go up.

 

It can start at maybe $15 or $16 an hour going up to about $20 an hour, wouldn't you say? Yeah, and if I could add to this, the kids will come to professionals, and they'll say, oh, I'm just going to hire so-and-so to come into my home, and that barely scratches the surface. And then it gets described to them the ways that they can secure home care, and you can see the complexity overwhelms the kids. So I have to attribute Vital Living for even doing this series because I would like for the elder to understand and the families to understand that when you start talking about home care, it's very complicated.

 

It's just very complicated. So how do you determine what type of professional is needed in terms of how do you make the recommendations? What are some of the things that they need to be considering, that the kids, the family needs to be considering? They need to, first of all, be sure that the person is background checked. I mean, you want to make sure that the person that you're bringing into this house that's going to have access to a lot of stuff is a trustworthy person.

 

There's a variety of ways that that can be done, but I always recommend that people use an agency that has that already in place because it's a lot simpler. You want to make sure that the caregiver is a good personality match. And so what people don't understand is that they sometimes think that they have to accept the aid that shows up at the door, and it may not really be the right person.

 

It might need to be a couple of people that you have to go through before you find that right personality match. My dad had a very significant dimension. He had a very paranoid thing about people coming into the house.

 

We went through a variety of caregivers, but the way I finally got him to accept a caregiver was I told him that she would be a personal assistant to him, that she would do things that he couldn't do any longer, that she would be his arms. I went out to get groceries and came back, and my father had her digging up the sprinkler system. So he took that a little further.

 

You know what? That aid has been with us for over 16 years. Dad's passed away. She's now taking care of my mom.

 

She looked at me, winked, and said, I think I passed the test, and now I know how to change sprinkler heads too. Now one of the things that I know people are obviously considering is, what does everything cost? So how much of a role does finances play in this? Well, it's the guiding force. If you can't afford it, it's not an option.

 

So the very first conversation is, what's your long-term budget? And here's what I would say to the kids. The elder has saved, and then they get to where they need to spend their savings, and they don't want to do it. So that's like the landscape that they're working under.

 

But if an elder is on a fixed income, and it might not be realistic to pay for home care, so if they have a budget of $3,000 a month and it's going to be $5,000 a month to get in-home care, then we have to look at a less expensive alternative. So the finances is the driving force. And what I recommend people do is try to get help finding money out there that might help pay for the care.

 

It takes some coaxing for them to be comfortable talking about their money with their children. It's a really intimate topic, and sometimes having people there to help get that conversation going, it breaks the tension to say, okay, now you've saved, here you are, and it's okay to spend. This is what you've been saving for.

 

And I find that most kids really don't want their parents' money. They really want their parent to live well and healthy. There are those who may have a different slant on that.

 

But for the most part, the people that I see are really people who are deeply concerned about their parents getting the best of care, and they're not as concerned about parents spending money, but the parents are concerned about it. And they're so fearful of spending more than they bring in because all their life they have lived within their means, most of them, and then the thought of dipping into these assets is very fearful. And it's funny because there can be patients, some of my clients that have plenty of money probably couldn't spend it if they started today.

 

And they still have that fear that they're going to outlive their money and that they're not going to have enough. So as we talk about finances and elders who maybe don't want to spend the money, are they also intimidated about what it actually costs? Oh, you should see their faces when we say, if you want 8 hours of care a day for the month, it'll be $3,000 a month. And they are aghast.

 

They are absolutely. And when I hear myself saying it, oh, the nursing home cost is now $8,000 to $9,000 a month, I feel like it's a lot of money. So for them, it's always shocking.

 

And people always think, well, I'm just going to stay home. They're not realizing that that can be the most expensive option. I mean, staying home is not always cheap.

 

And people get to be prisoners in their own home, so home isn't always the best place. So socially they get isolated and every other thing. Right, and then I'm not going to spend, I'm not going to spend, or I'll get care next month or the next month, and then they have an accident, they fall, break a hip, or something happens, and then it's a really expensive type of care.

 

So what we say to people is start off with a little bit so that you can prevent a really big expensive health care bill. Right, right, absolutely. So give me an example of when families typically realize that they need some help caregiving, whether it's in the home or outside of the home.

 

What point are they at where they come to you for more information? Usually it's crisis, isn't it? Well, usually it's crisis, but there's also a stage of compromise, which is mom is kind of not wanting to go to the grocery store anymore. It's really weird, so they get uneasy. They come home for Thanksgiving and mom hasn't been taking meds, or she's a little confused, she's obviously lost some weight, the house is a mess, there's some late notices sitting on the table, maybe there's a little hoarding behavior beginning.

 

And then they bring it up and the mom or dad says, No, no, no, I'm fine. Everything's fine. My doctor says I'm doing great.

 

And they're afraid to go home and put their kids back in school because obviously she's not quite all right. And now what do we do? And I'd say that's a really typical scenario, wouldn't you? It's a realization that, oh, boy, we can't really ignore this anymore. We can't just let this go.

 

How do you convince, whether it's kids or the elders, that something like this is the right thing to do? It's time. Well, I'm going to say I stage that conversation for later. First I try to get them to talk about how scary it is because everybody doesn't want to talk about it because everybody's scared.

 

The elders are scared that they're in the stage of the end of their life. The kids are afraid of looking at the decline of their parent. And so everybody's scared.

 

So if you can get all that kind of brought up, then talk about, you know, this is a really tough time, but it can be a beautiful time. So let's kind of work together to make this time as productive and well as possible once you get that angst up and sorted through. Right, and I think a lot of times kids are afraid to say something.

 

There's still that parental role, and they're a little afraid to say something disrespectful. If their parent, even though Mom may be doing some really crazy stuff, they may be afraid to have that conversation in front of her. So oftentimes it might be the kids that begin the conversation with me, and we bring Mom into it a little bit later in because then I have an idea of what I'm looking for and what I need to really assess without overwhelming the parent.

 

It can be a very daunting type of thing. It doesn't have to be. But a lot of times people are really, it's an emotional time.

 

It's a very emotional time, and sometimes it's under a time crunch because they have to get back to work or they have to get back to, they're from out of state and they're only here for the weekend or whatever, and so they're under a crunch to get something accomplished quickly. And usually they want it to be a big thing. We encourage something small.

 

Baby steps. Yeah, baby steps. I'll use my dad as an example.

 

He's 85, and it's taken us a year to help him understand the value of a cane, and now he's using it. And it's taken a year. So I went up to see him.

 

We went to the airport. He sat down. I realized he didn't have his cane.

 

He realized he didn't have his cane. I sat there holding my breath, and he leaned over and he said, I forgot my cane. And I felt like that was progress.

 

So sometimes it's not the big move to assisted living. It's not the big move getting a caregiver. It's a little something that says, okay, I'm open to getting help.

 

And those baby steps are really important because it can really set a senior back making a big move, because especially if they're starting to really rely on routine to function, and then suddenly you pull them out of their routine, you can really see them go downhill fast. So we'd really try to work with the situation that they're in and start to introduce maybe a person that, like with my father, she was not going to do personal care. He wasn't going to get naked with a lady that he barely met.

 

And so at the beginning, she actually went fishing with him. She did things that were fun with him. He got to know her.

 

He felt more comfortable. And then as his physical frailty started to become more apparent, he was more willing to let this woman sort of be more involved in personal care. I've had a couple of seniors where they wouldn't let them in the house.

 

I mean, they'd lock the door, and the caregiver was on the other side of the door. So we didn't try to bring them in the house. We had them drive them to the grocery store and to the doctor's appointments and so forth.

 

They were more of a driver than they were of a caregiver. And it gradually brought that person in. Then when we had to make a move, that person went with them, initially at least, to help them adjust to the new environment.

 

And it wasn't such a traumatic. Everybody likes to wrap it up with a bow. It comes unwrapped.

 

These are people. It's never going to stay tied. You're going to have to be flexible and kind of work with it.

 

And I would imagine independence is also an issue. I know for our family, with my grandmother, who's in her 90s, when she had to bring a caregiver in, it was giving up a little bit of that independence and letting someone into your home when you have your routine and your way of how you're living. Oh, it's so true.

 

I can tell when I walk into a home that the elder is thinking this is the beginning of the end. And it really is. And so not the beginning of the end like death, but it's a change.

 

And every change is an ending and it's a beginning. But that's a really dead-on statement you're making. How does the care plan help not just the elder but the caregiver as well? So we go back to the plan here.

 

Having this plan in place is beneficial all around. It's all around. What I would say the big benefit of a care plan is for the children to be able to step back and see that the goals are being met.

 

So I'll give you an example. We had a woman we helped move to an assisted living facility. And the son called, and he just was upset, upset because she's still wanting to come home.

 

Every time I see her, she wants to come home. He was so frustrated and emotional. But she was in the facility eating three meals a day.

 

She was starting to go to activities. But when he went there, he didn't want to hear anything negative. So the care plan was we're going to get her moved and stabilized, and that had been met.

 

So when I talked to him, he just calmed down because he thought, oh, okay. It's a process. It's a process, and we did it.

 

So it helps the kids, I think, with their own perception and their own expectations to keep them realistic. It's objective, and you're setting a roadmap. And they can see the steps along the way.

 

I think that helps. And also sometimes you have to project it out a little bit because maybe they've been newly diagnosed with Alzheimer's, and we know what it's going to look like in about two years, but they don't. So helping them understand some of the steps along the way and the milestones that they're going to hit, just like watching a baby grow.

 

This senior is going to go through some phases, and these are the kinds of things, so that when they see it, it's not so shocking. And it's really in your face, and it's really hard to watch your parent go through that. But when somebody professional has lined that out for you, it's not quite as scary.

 

They see that it's just the progression. Well, it's definitely a roadmap, as you say. So Patty and Amy, thank you very much.

 

It is time for a short break. And when we return, we'll begin to talk about how to identify an elder's needs and begin to look at how a care plan is developed. We'll be right back.

 

Welcome back to the Vital Living Forum on developing a care plan for an elder whose health is declining. I'm Katie Dagenais, and with me are Patty Antony and Amy O'Rourke, both professional care managers. Thank you for being here with us today and staying with us.

 

Let's go ahead and start. Patty, can you tell us what is the first step in developing this care plan that we've been talking about? The first step, I think, is meeting. I generally like to meet with the children first, without the parent, because they can tell me things that they may be afraid to say in front of a parent.

 

And also parents get really overwhelmed with the length of time that it takes to have those discussions. We'll start with just talking about the situation, what kind of help they're looking for. It's kind of funny because usually I'd say 50% of the time what they're looking for or think they're looking for is not what they end up with.

 

But they'll tell me the story of what they're seeing, where their concerns are, maybe some health history on mom. I like to get a complete list of medications and kind of get through what other issues, because sometimes there's maybe diabetes in there or some other things that are going to play in later for what kind of caregiver we have to utilize. We start with that.

 

I look at the support system of the family, how much involvement they can have. Some of them are out of town and there's not going to be much. Sometimes parents are living alone or they're widowed and they're really alone.

 

So we look at the support system. I look at the finances pretty heavily because that is going to help to drive where and what we can do. So we go through a pretty detailed explanation of where the finances are and how things are set up.

 

I like to know who their practitioners are. So it's really an assessment of many different areas, and you've touched on a couple of them. Let's kind of go through some others as well.

 

You mentioned medication history. Why is that so important, Amy? Well, there's three main reasons an elder goes to a hospital unnecessarily, and one of them is medication. So let's just put that right out on the table.

 

There are medications, the amounts and the types, sometimes with an elder, particularly with a memory impairment, create problems with behaviors that are oftentimes not addressed. So that becomes really important to look at to see if that's happening. And we sometimes secure help from the physicians or geriatric psychopharmacologists to look at that and make some recommendations.

 

And sometimes it's just a little tweak of the medicine can help change the stability in the home. And it's amazing how many seniors hoard medications because they're expensive. And even though they aren't taking them anymore or they were allergic to them, they spend all that money on them so they don't want to throw them out or get rid of them.

 

So I found apothecary bottles that were glass that were probably 30 years old. The bottles were worth way more than the pills. So that's a big issue, actually.

 

Medication is huge. And then sometimes people have memory loss, so they can't remember to take their medications, and they might need reminders or systems in place to help them remember. And sometimes it's funny with an elder who's resistant to care.

 

If you can take medication, that's something that's concrete and understandable. And if you help them with that area, it builds a level of trust that you can then move over to another area that they might not have felt more comfortable. So it can be an easy bridge to other issues that they might not be so open to getting help over.

 

And one of those issues is just functioning in daily life, I would imagine. Correct? That's another issue? It is. It is.

 

I call it energy depletion. So every decade that goes by, you lose a certain amount of energy. So when you hit 80, you hit 85, you have even more limited storage of energy.

 

So if you have to go to five different doctors, that's your life. And then the kids are saying, hey, I want you to go to the Y three times a week. And they're saying, all my energy is on going to the doctor.

 

It's a part-time job. So we help look at the elder's life and look at what they're expending in terms of energy, where it can be pulled down and put towards things that they deem important. And as a physical therapist, I'm really big on that energy conservation thing because sometimes bathrooms need to be modified in order to get in and out of a shower much easier.

 

If you have a tub shower situation, stepping over the tub might mean the difference of a person bathing or not. They really start to avoid that tub, and they start sponge bathing and some other things. So looking at how can we make this an easier thing so they're not burning up all their energy just to get through a shower.

 

One of the other things that you look at, the level of assistance that they need and that they currently have. Correct? Correct. If a person's having a lot of trouble getting in and out of bed, it might be that we need a caregiver just for that couple of hours in the morning to help them get started.

 

And once they get started and on their feet, they're okay. We call it the drive-by. Yeah, that's right, the drive-by.

 

And we do the drive-by sometimes twice a day. You do a split shift where you have somebody coming in from the morning, reversing in the afternoon. Let them have their day, and then at the end of the day, wrapping them up and getting their dinner, and then they can go to bed and be fine for the night.

 

Right, and getting their medication, too, as well. So there may be needs for that at the beginning and at the end of the day. Right, and sometimes, too, there's some really amazing technology out there.

 

So using a computerized medication box that automatically dispenses, they have one that actually has a voice that says it's time to take your medicine. It used to beep, but everybody went to the microwave. So now they have this computer box that says, come take your medicine.

 

They push a button, the pills dispense. And that's one of the main reasons, I think, that people go to assisted living is that parents are starting to take their medications improperly or skipping them or picking and choosing which pills they're going to take today, and they're not taking them properly, and the next thing you know, they're sick. So some simple things like that, even just a pill box, that maybe an aide can help them remember to take, but it may be set up by a nurse or by a family member.

 

Those kinds of things can make just all the difference in the world for a patient's independence. Right, meal prep. Here's your meal.

 

It's out on the table. So they don't have to do anything but sit down and eat it, and they don't have to spend that energy trying to just prepare the meal. Right, standing at the stove.

 

By the time the food is ready, they're exhausted, and they don't even feel like eating now. But also there's depression that comes into this too, and when somebody's living alone, I know when I'm alone, I'm not really in the mood to cook. If there's nobody to cook for and there's nobody to eat with, you tend to graze, and so then you start to run into a lot of nutrition issues that go with it or sickness because they're taking their meds on an empty stomach.

 

Or you add the memory impairment, and they eat and eat and eat because they've forgotten that they just ate, or they don't eat thinking that they ate. So there are a lot of components to the assessment. How long does it usually take to do the assessment? I would say it depends.

 

I feel like a politician. Mine usually takes, I can't usually get them done in under two and a half hours. Usually between two and two and a half hours, and that's why I start with the family first and not the senior.

 

Right, right. It really depends on what they can tolerate and how you stage it out. But I would say an average time would be a couple of hours.

 

And as you're working on the assessment, you're looking at goals. Let's talk a little bit about the goals because everyone maybe has different goals. They may not match up.

 

That's the key to the whole issue. So the most important thing is getting all the goals out on the table. What are the kids' goals? What are the elders' goals? And then picking one, I think, that everybody can agree, if we can do this one thing, which might be three meals a day, might be two meals a day.

 

Something simple. Something simple. We're going to start there.

 

And then we help the kids get help with their expectations, going back to what we had said earlier, and getting the elder to bond over something else that's important to them. Okay. I'm sure Patty asked this question, too.

 

What, to the elder, is your most pressing worry? What do you think about throughout the day that bothers you? And we try to have that be a goal to fix. And falls is a big one. Yeah.

 

People are paralyzed by the fear of falling. Right. And to the extent that they almost make it a self-fulfilling prophecy sometimes.

 

Oh, right. They'll sleep in their chair. Absolutely.

 

All night so they don't have to stand up and go to the bathroom. Right. Okay.

 

Right. And going to the bathroom is a huge issue. And you'll see people start skipping their diuretic because they don't want to have to go to the bathroom.

 

Yeah. Some of the medications that they take might make them really groggy, and their blood pressure might drop when they first get up. And so teaching them how to do positional changes and so forth so that they are a little safer.

 

I try to make people see me as a resource person, though, not as a, I'm not going to direct your life. Right. I'm just going to help you figure out some options for the solutions.

 

And that helps. And the senior doesn't feel like there's somebody coming in and taking over. Right.

 

And then another factor in the care plan thing would be then what are we going to look for in the future that would indicate we're going to adjust this care plan. Sure. Right.

 

And making sure that they have a little glimpse of what the future might hold. Right. And when you would do that.

 

And when you would do that. Right. And so how do you actually get to the development part of this? And what is involved in developing this care plan? Well, Patty and I may or may not have different styles.

 

I don't know. Well, I don't like to use the language of a care plan with an elder. I keep that language with the kids.

 

Because if you use care plan with an elder, they feel like the patient and that's just a term. Like they're being taken care of. Right.

 

That's right. Right. So we develop the care plan with the kids and work up the goals.

 

And we just say to the elder, what things are important to you, and this is what we're going to be a team to approach. And we leave all that academic health care language out of the way. And then with the kids, we say, you know, through an email or through, you know, a phone conference, these are the projects that we're working on.

 

This is the goal. This is what we're going to know when we're going to know we've attained it. And then time frame.

 

And usually the first 90 days it looks differently than when it's going to look after the 90 days. Because things kind of take a few months to stabilize. And then what are we going to know is success.

 

And define that. And then making sure that we have a set time to follow up on those goals. And people need to realize that it does take time.

 

I mean, you can't rush it. And much as a lot of type A people would like to have that list, get them nailed down, it just doesn't work that way. You have to kind of go at it in little pieces and help the person get there, you know.

 

And then, of course, you end up with five siblings that don't agree. Right. And it seems like the one that lives the furthest away is the one that has the strongest opinion.

 

They have the strongest opinion. Right, yeah. But trying to just help people.