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Helping You Make Informed Choices for Care

August 15, 2017

By Jan Klingberg

You are 70 years old and you’ve just had hip replacement surgery at Lutheran General Hospital—or another area hospital—and are about ready for discharge. Chances are you have met one of the case managers from North Shore Senior Center’s Choices for Care program!

After your physician wrote an order for your release to a skilled nursing facility for short-term rehabilitation, the behind-the-scenes work of discharge planning immediately kicked into gear. A hospital social worker likely asked which facility you preferred. Before you could actually be transferred, though, a case manager from the Choices program stopped at your bedside. This visit was to verify that you needed skilled care and to provide information about all of the options for care available to you.

The State of Illinois created the Choices for Care program in 1996 to address costs and quality-of-life issues related to institutional care versus care in the home. The Center is one of several organizations statewide that has a contract to prescreen seniors before they are placed in an extended care facility. This pre-screening—or an immediate screening after placement—is required to confirm that skilled care is the best option for the patient’s safety, care and comfort.

For example, George (the patient’s name was changed and some details altered to protect privacy) had undergone an intensive inpatient treatment process for an autoimmune disorder that caused progressive muscle weakness. He had improved enough with therapy for his doctor to recommend that he could continue his rehab in a skilled care facility. Ning Sun, MA, supervisor of the Choices for Care program at the Center, received the referral to do George’s pre-screening before his scheduled discharge. Ning talked with him about his ability to care for himself, his home situation, and how he was doing. Ning learned that although he was feeling stronger, he still had considerable numbness in his feet and a bit in his hands. He could cut his food and feed himself, brush his teeth, and wash his hair. Yet getting into the bathroom to shower or use the toilet was a challenge. Ning also could see that George was alert and able to make his own decisions about care. He understood that going to a facility for short-term rehab was the best way for him to recover and regain strength.

But George was apprehensive about how he would manage after his discharge from a skilled nursing facility. He already had decided to live with his daughter for a time until he was ready to return to his own apartment. George and his daughter were both concerned, though, about how he would navigate the stairs to the second floor bathroom or manage showering. The information that Ning provided helped to relieve his mind. He learned that community resources abound to help seniors at home, such as a home-care assistant who could help him shower a couple of times a week.

The screening process gives seniors and their families the opportunity to ask questions, discuss their needs for services after a prescribed stay in a nursing facility, and learn about community-based and institutional options for continuing care. In 2006, Ning and her staff of 12 case managers conducted the physical, cognitive, and emotional screening process for more than 10,000 older adults. Yes, that’s 10,000! Ning and some of her staff are based at Advocate Lutheran General Hospital. Other case managers work out of one of five other hospitals in the Center’s service area: three hospitals that are part of NorthShore University Health System (Evanston, Glenbrook, Skokie) and two in the Presence system (St. Francis and Holy Family). Choices for Care case managers provide screenings seven days a week.

Although an extended-care facility might seem like the best option for a senior who has limited ability to care for himself or herself, institutional care could make it difficult for a patient to transition back into the community. “Prescreening should be viewed as an opportunity to prevent unnecessary institutionalizations,” states the Illinois Department on Aging (IDoA). The aim of IDoA is to help seniors remain in their homes and live independently as long as possible by providing in-home and community-based services. That aim meshes with the mission of the Center, which is to foster independence and well-being, enhance dignity and self-respect, and promote participation in community life.

Ning commented that George’s situation is straightforward and uncomplicated. But the case managers in the Choices program also encounter patients whose circumstances are more challenging. “Choices case managers would be unable to communicate with a patient who is intubated or not fully alert,” she said. Since no meaningful conversation could take place, they would have to gather information from other sources—medical charts, hospital staff, family members—to complete the assessment. In many such cases, case managers must use their best professional judgment about the situation, including knowing when to back off if the patient or family is too stressed to handle a visit. In Ning’s 20 years of experience in the Choices program, she has learned to respond compassionately to tricky situations, glean important information from whatever and whoever is available, and identify patients’ care needs in a short time. She coaches her staff to do the same.

Another situation a Choices case manager may encounter is a patient whose self-neglect is evident. Mental health support might be helpful once the patient is discharged from skilled care, but the person might refuse the assistance. “Often in self-neglect cases,” commented Elizabeth Gordon, Ph.D., director of North Shore Senior Options (formerly CareOptions), “the person is cognitively able to say, ‘Not interested’ and we have to respect that. Autonomy and self-determination is considered in all of the services provided by the Center.” Exceptions include concern about harm to self or others.

Armed with the information he received from Ning, George could contact the Center to arrange for essential services. The Center is the official entity— the Care Coordination Unit (CCU)—authorized by the state to conduct assessments in this area to determine housing, financial, personal care, and housekeeping needs of seniors and to discuss available services. Social services case managers complete the IDoA 21-page assessment on each client referred to the Center’s Central Intake by a long-term care facility, hospital or the family itself.

After receiving a call from George or his daughter, the case manager would do the required in-home assessment to learn about his specific needs and help develop a care plan. Some of the services George might use—e.g., personal care and household tasks or the loan of durable medical equipment—might be provided by the Center. Other services, such as light housekeeping or home-delivered meals, would be delivered by another area senior services provider. Depending on the older adult’s assets, some services are funded by the state and federal government and others can be purchased by the client. The web of state and federal government programs for seniors is complex, so the Center’s role as a CCU is crucial to the well-being of older adults and their families.

Whatever the person’s care needs after hospitalization may be, the important, unified message from the state, the Center, and case managers who are on the front line of service is, “You are not alone. You don’t have to navigate this by yourself.” That reassurance is a major factor in enhancing the well-being of older adults and helping them avoid isolation, which can become a real negative force affecting their health and longevity. And with the appropriate services wrapped around a senior who has returned to a safe home environment, the chances of readmission to the hospital or rehab center are reduced.