Multiple Transitions: Moving an Ailing Parent Close to Home
Sandy first contacted Debbie about her out-of-town widowed mother, Mrs. A., concerned about her memory problems and her mother’s difficulty in managing her medications. After some discussion, Debbie referred Sandy to a colleague whom she had met at a national conference who lived near Mrs. A. Sandy retained this Aging Life Care Manager® (ALCM) to help assess her mother’s needs and to be Sandy’s eyes and ears on the ground.
As Mrs. A’s health declined over the next two years and her care increased, the distance helped Sandy and her mother make the decision to move Mrs. A to a different care setting near Sandy in Central Massachusetts. Sandy again consulted with Debbie, who recommended several assisted living facilities. Sandy and her mother visited these options, made their selection and arranged for the move. After the move, Debbie assisted in identifying new physicians to care for Mrs. A and helped the family contract with a private aide who could take Mrs. A out during the week when Sandy was at work. As Sandy had a lengthy commute, she relied on Debbie to represent her at routine care plan meetings, work with the care agency and negotiate issues with the facility.
Over the next five years, as Mrs. A’s health continued to decline, Debbie worked with Sandy to make needed adjustments to the care plan. The private aides came daily for many hours at a time to supplement care at the assisted living facility. Eventually, as Mrs. A’s needs became too extensive for that treatment setting, Debbie assisted Sandy in the challenging process of applying to a nursing home and having the initial discussion with Mrs. A about the need to make the move.
Once Mrs. A was settled in the nursing home, Debbie assisted with filing a claim with the long-term-care insurance company and dealt with regular reviews of the claim. She continued to attend routine and special care plan meetings both with and without Sandy, and to provide a source of moral support. When it became clear that Mrs. A was approaching the end of her life, Debbie and Sandy had many difficult discussions about hospice and the decisions that Sandy needed to make for her mother. Debbie sat with Sandy during some of her mother’s final hours. Following Mrs. A’s passing, she helped to clean out the nursing home room of special papers and objects, and also assisted Sandy in notifying Social Security, insurance providers and others.
Surrogate Niece: Caring for a Loved One Long-Distance
Rachel, who lived out-of-state, was referred to us by a friend of hers in Worcester. Rachel was concerned about her elderly uncle, a single man in his nineties living alone in an apartment here. While Mr. C was still alert, oriented and managing, Rachel felt it would be a good idea to identify someone who could assess the situation, make recommendations and be available in the event of an emergency situation or other changes.
Mr. C reluctantly agreed to meet with Debbie, telling her that he was only meeting “out of courtesy to my niece.” At that first meeting, Mr. C confessed to being concerned about his isolation from others and his risk of falling. While he didn’t feel ready to move to a different care setting, he allowed Debbie to make a referral for a personal emergency response system and to purchase a tub seat. He agreed and promised to stay in touch in case there was anything else he needed. He subsequently called for information about potential drivers.
Several months later, Rachel called in a panic saying that her uncle felt that needed to be in a nursing home. Debbie went to see Mr. C, who was still managing on his own. However, it had been a very cold, icy winter and Mr. C had been confined to the apartment for weeks. He stated that he wanted to move to a particular assisted living facility but was concerned about all the issues involved in moving out of his apartment.
Debbie spoke with him about going to the facility for a respite stay, both to try it out and to forestall the need to make any big decisions about the apartment and his belongings. He agreed, and Debbie was able to obtain an apartment and complete the paperwork within the week. He moved with Debbie’s help packing a few suitcases. Two days later, Mr. C announced that he wanted to stay in the facility. Over the coming months, Debbie worked with Mr. C and Rachel to make decisions about the furniture, hire a mover (who also took all of the unwanted items) and terminate his lease.
As time went on, Mr. C required more assistance with financial management and attendance at medical appointments. He fell in his apartment and this led to placement in long-term-care. Debbie assisted with the transition, including moving items into his new home, and continued to visit at least monthly, attend care plan meetings and assist with all paperwork related to the MassHealth subsidy. She consulted with the family about care decisions to be made as his health declined. At the time of Mr. C’s passing he was nearly 102. Debbie assisted with the close-out of his room and distribution of personal effects. He had been a client for 10 years.
Age Is No Limit: Traumatic Brain Injury
A local attorney referred the family of Mr. O, a younger man who was extremely impaired from a traumatic brain injury. Mr. O lived in a nursing home and was unable to communicate with others. His family lived out of the country although they served as his legal representative. They retained our services to be their local eyes and ears. Susan visited Mr. O monthly, spoke with his physicians and nurses regularly and ensured that he was treated with dignity at all times. Susan also purchased needed items for Mr. O. When Mr. O was hospitalized, Susan visited daily and spoke more often with the hospital care team. She attended all out-of-facility physician visits and communicated concerns between the various caregivers.
Susan reported regularly to the legal guardian and had initiated difficult conversations about care needs and planning. With her compassionate guidance, Mr. O’s family was able to agree to funeral planning and to implement clearer orders for care in case of a sudden change in Mr. O’s status. Upon his death, Susan worked with the family and funeral home to meet Mr. O’s final wishes.
Managing Alzheimer’s: Caring for a Beloved Spouse
Mr. P and his daughter were concerned about Mr. P’s wife, who is suffering from Alzheimer’s Disease. Mr. P was still working and left his wife alone during the day, although he left work multiple times daily to check on her. Recently, a friend had witnessed Mrs. P outside of the house, crossing a busy street to check on the mail. The family was very concerned for her safety while, at the same time, Mr. P and his family were committed to keeping Mrs. P at home.
After a lengthy discussion, we identified a community program that could provide the kind of care needed for Mrs. P—out-of-home care during the day while Mr. P was at work, and assistance at home with personal care in the evenings and on weekends. We encouraged the family to tour the program and to have a consultation. As the family worked through Mrs. P’s transition, we helped to mediate issues that arose. We assisted with the necessary MassHealth application and with a needed adjustment to Medicare benefits. Once Mrs. P was enrolled and settled, active involvement in the case was not needed but our team remained available for annual financial reviews and other issues.
After Mrs. P had been in the program for several years, the family contacted us regarding behavioral changes and concerns about medication. We consulted with the family in preparation for a care plan meeting and discussed when a move to a long-term care facility might be appropriate.
Maintaining Independence in a Complex Situation
Mr. G’s family was concerned with his living situation and his ability to receive the care he needed in his home. Deb met and assessed Mr. G’s current situation. He agreed that to receive the proper level of care he would need to move into a facility. Mr. G was very reluctant to do so. Nicole worked with Mr. G to discuss the move to an appropriate facility. When Mr. G agreed Nicole worked to find the best fit for Mr. G and his care needs. While Mr. G was in the facility Nicole met and spoke with Mr. G and facility staff regularly. Mr. G had no local family so Nicole was able to bring Mr. G needed items while he stayed at the facility. Mr. G also realized that he could use assistance while attending medical appointments and asked Nicole if she would be willing to attend. Nicole would attend each medical appointment and prepare a summary to send to Mr. G as well as his long distance family members.
When Mr. G was ready Nicole assisted him in developing an appropriate care plan to move back home. With proper care at home Mr. G was able to receive care in the setting he preferred. When Mr. G. did move home Nicole continued to stay involved. She arranged for additional services as needed, attended medical appointments with Mr. G, coordinated with the multiple in home providers and provided Mr. G’s family with regular updates. Mr. G. continues to live successfully at home.