The Story of Needing a Geriatric Care Manager in Tallahassee, Florida
Senior Transitions is happy to present a true-to-life story about a family going through the process of learning that their aging parent is not living their best life possible and the steps they take to get help. Read how they discover that their mom is having issues in her home and step through the process of figuring out why she is having issues and the professionals that they bring in to assist them. If you are facing challenges with an aging parent or grandparent in the Tallahassee area, we are available to help your family solve the issues and reduce the family’s stress. Please enjoy the story about how geriatric care managers (also known as Aging Life Care Managers) help families every day. You do not have to go through this alone.
We Needed A Geriatric Care Manager
By: Angela Grayson
Living an hour and a half away from Mom, I didn’t visit her as much as I wanted to that summer. It seemed there was always something going on at our house. When I wasn’t picking up my 11-year old son, Alex, from summer camp and juggling my full- time job as an Office Manager at an insurance company I was taking my 17-year old daughter, Dana, to visit college campuses on the weekends. All this running meant that I barely had a moment to myself. My husband Bill tried making my life easier by picking up groceries and helping with other household tasks. But even then, there were times I felt like I was on a treadmill, permanently stuck on high speed!
I realized, with a hefty dose of guilt, that I hadn’t seen Mom since June. We’d had a family picnic at the lake and Bill had gone to pick Mom up while I got things ready. Thinking back, I remember that she’d seemed subdued that afternoon, not quite her usual animated self. The day had gone okay, and everyone had devoured the food and enjoyed the beautiful view. Even Mom, who sometimes said she didn’t have much of an appetite, had eaten well. Bill took her home in the early evening. After the picnic I called her often, but I noticed that our conversations were short and sweet, which was not the norm for her.
When I would ask her how things were going, or how her recent doctor’s visit went, she would say, “I’m doing fine.” She’d told me that her friend and next-door neighbor, Nancy, was taking her to the appointments. At age 78, Mom had a few health problems that worried me. She had diabetes and congestive heart failure, which were both controlled by medications. She had regular appointments with her doctors and her conditions were carefully monitored.
Or so I had thought.
Mom’s 79th birthday was September 12th, and we’d planned a nice dinner at her favorite restaurant which was close to her house. The plan was that we’d pick her up at 5 p.m. Dana had a part-time job at a local pizza place and couldn’t make it, but Alex was with us when we got to Mom’s house.
In that moment, I realized something was very, very wrong.
Mom didn’t answer the doorbell for the longest time. While Bill and Alex waited in the car, I rang the doorbell again and again, my anxiety ratcheting up by the second.
Just as I pulled out my cell phone to call her, the door slowly opened. Mom stood and stared at me in confusion as though I’d grown two horns on my head.
“What are you doing here?” she asked. “How nice to see you!” She was wearing a pink stained housecoat, and her hair was disheveled.
“Mom, it’s your birthday! We’re taking you out to dinner at Max’s Seafood!” I managed to say. “Do you remember? I called you last night to remind you.”
She grinned, but I could tell from her confused expression that she really didn’t recall. “Of course! I’m sorry. I’ll get dressed.”
I motioned to Bill and Alex that I’d be a few minutes. I followed Mom into the house and down the hallway, taking in how different things were since I’d been here last. When had it been – sometime last spring? Mom had always been neat and tidy, but now her house was anything but. There were piles of mail on her kitchen table, dirty dishes in the sink, and newspapers on the floor. An odor of spoiled food wafted from the kitchen.
While she dressed in her bedroom, I flipped through the mail. There were several unopened bills stacked haphazardly on the table, along with junk mail and magazines. I opened the refrigerator and inspected the contents. There was a carton of eggs, a quart of milk that had expired weeks earlier, condiments, and a few containers of mystery leftovers. I opened one lid on a glass Tupperware dish and the smell of rotten meat made me gasp. I dumped the contents of the rotten food down the garbage disposal.
“I’m ready,” Mom announced, emerging from her bedroom. She wore a blue dress that I had bought her last year. It hung from her thin frame. She had lost a lot of weight, I thought. It was like a sucker-punch to the gut. Why hadn’t I paid more attention to my mother? How had things deteriorated to this point?
“Where are we going?” she asked, as we made our way to the door. My head was spinning.
“To Max’s Seafood,” I said.
Mom smiled and looked at me, puzzled. “Why?”
A Daughter’s Dilemma
Mom’s birthday dinner was a turning point for me. I watched her closely during the meal. While Alex and my husband chattered away, my mother often just nodded her head and smiled. There was a blank look in her eyes that made me wonder how much she really understood. She picked at her food and barely ate a thing.
My father had died a decade earlier of Alzheimer’s Disease. Was my mother also suffering from dementia? What was I supposed to do? I was her only daughter. My younger brother was married with three kids, living in Singapore. We hadn’t seen each other in years and I knew I couldn’t call him and ask him to keep an eye on Mom. I started to wonder whether my Mom’s neighbor, Nancy, was really taking Mom to her doctor’s appointments. I had met Nancy only once. She was retired but also not in good health.
When we took Mom home after her birthday dinner, I walked her to the door and waited until she found her house key in her purse. I followed her inside and put the carton of leftovers in the fridge.
“Mom, are you feeling okay? You were a little quiet at dinner.” “I’m doing just fine,” she said.
“Do you need anything? I noticed you don’t have much food in the fridge,” I said, testing the waters.
“You know, I get those meals every day,” Mom waved her hand. “I don’t need anything.”
I knew that Mom was getting Meals on Wheels, but that was only lunch, wasn’t it? “When is your next doctor’s appointment?” I asked, reluctant to leave.
“Tomorrow afternoon,” she said, a little too quickly. “I see Dr. Goldman, the heart doctor. Nancy’s taking me. Honey, I told you I’m fine. What’s with the 20 questions?”
I hesitated, then dove in. “I’m worried. While you were getting dressed, I saw that you have some bills on your table and the envelopes aren’t open. Are you paying your bills? Are you really getting to your doctors’ appointments?”
“Of course, I am!” Mom’s voice rose. “And why were you looking at my bills? Why don’t you mind your own business?”
Even though she was scolding me like a child, I felt as if the roles were reversed, and she was the child.
“I just want to make sure you’re okay. Are you taking your meds every day?”
My mother gave me the stink-eye and motioned at the array of pill bottles on the kitchen counter. “Yes! Are you happy now?”
“What about those bills on the table?” I persisted. “They look like they’ve been there for weeks.”
Mom sighed. “Leave me alone, will you? Is the electric still on?”
“Yes, but -“ “But nothing.”
“I just want to make sure -“ “Sure, shmure. I’m fine.”
I could see I was only aggravating her. I paused and checked the calendar on my cell phone. No meetings in the afternoon. My boss was understanding; he would let me leave early. “How about if I take you to your doctor’s appointment tomorrow?
What time do you have to be there?”
Mom looked puzzled. “No, no, that’s okay, Nancy’s taking me.” She glanced at the large wall calendar where she usually had her appointments listed. Tomorrow’s date was blank. “I think it’s at 2 o’clock.”
“Do you have an appointment card?” I asked gently. “We can check the time.”
Mom opened her purse and fumbled through the zippered pockets. Finally, she produced a small white appointment card and handed it to me.
I looked at the time and date. “Your appointment was for last Friday, Mom. Last Friday at 3 p.m.”
Mom took the card back and peered at it closely. She put it back in her purse and snapped it shut. “Yes, I went then.”
I took a deep breath. It was no use arguing with her. I would call her doctor first thing tomorrow morning and find out what was going on.
“You better get going,” she said. “I’m tired. I’m going to watch my shows and go to bed.”
We hugged goodbye, and I went out to the car, where Bill and Alex were patiently waiting.
The First Call
On my work break, the next morning, I called Dr. Goldman’s office, hoping that my mother had listed my name on her HIPAA forms as someone they could communicate with about her health. Thankfully, my mother had done that.
“Well, Mrs. Grayson, your mother was scheduled for an appointment last Friday, but she didn’t show. We’ve tried calling her but have been unable to reach her and she has not returned our call.” The receptionist seemed sympathetic. “She missed her appointment last month also. Do you want to reschedule? Would it be possible to have someone come with her this time?”
“Absolutely,” I said, feeling alarm bells go off in my head. Did Mom forget, or did she just dislike the doctor and decide not to go? If so, it wouldn’t be the first time she’d ‘voted with her feet.’ I felt that I needed to know more and asked if I could leave a message for Dr. Goldman to contact me.
“Of course. I’ll give him your message,” the women said, and took my contact information.
I waited, keeping an eye on my cell phone. Later that afternoon the call from Dr. Goldman finally came. He reiterated what the receptionist had said about Mom missing appointments and added that it was important for my mother to have her heart condition closely monitored.
“I’m really worried about her,” I said, and explained that I didn’t live close enough to check on her every day. My mind was racing. I told him I would come with Mom to her next appointment. I could already imagine her reaction when she found out I’d talked to him.
“Have you ever tried working with a geriatric care manager?” Dr. Goldman asked. “Some of my other older patients have families that live far away, and they’ve hired care managers who have really helped them out.” He seemed genuinely concerned.
I’d never heard the term ‘geriatric care manager.’ Dr. Goldman gave me a brief explanation, and said he’d transfer me back to his office staff. They could give me some names of care managers in the area. While I waited to be transferred, I started Googling ‘geriatric care management’ on my computer. Hmmm. I’d had no idea.
The office staff gave me two names and their contact information. I picked the one whose office address was in the same town where Mom lived. I wasn’t sure what I was going to say or what questions I was going to ask. I wasn’t even sure how any of this worked. I knew I had to do something so I took a deep breath, and made the phone call to Jennifer Masten, a registered nurse and geriatric care manager.
# # #
My first impression was that Jennifer – or Jenny, as she asked me to call her, knew exactly how I was feeling. I told her about the birthday dinner with Mom, and how uneasy I felt about the condition of her house, and her missing her medical appointments.
“I’d like to set up a time to meet with you and your Mom,” Jenny said. She explained how she worked with families. The first visit was an assessment of Mom’s situation: her emotional and physical health, her social needs, and her environment.
“What if Mom can’t live alone anymore?” I asked, and Jenny mentioned that was a justified concern and she explained that she would also make recommendations about safety.
“It depends,” she said. “Some seniors can stay at home as long as they have the right support. Sometimes that involves in-home care and some home modifications – but I’ll have a better idea of what to recommend after I meet with you and your Mom at her house.”
After more discussion, I felt like a huge weight had been lifted off my shoulders. I’d found someone who understood the situation. Someone with a nursing background who could help me figure out what to do. Jennifer’s services wouldn’t be covered by Mom’s health insurance, but her hourly rate was reasonable. We’d start out with an assessment and take it from there. I talked with Bill, who agreed it was the right decision.
But – I worried that Mom would resist meeting with Jenny, and I approached the subject gingerly on the phone later that night.
“Mom, would you consider talking with me and a nurse who wants to make sure that you’re doing okay and getting good care?”
“I know you’re fine. But would you do this for me? Just meet with us next week. I promise it won’t take long and she’s very nice. Okay? How about Tuesday night?”
There was a long pause. “I guess so,” Mom said doubtfully.
And with that, I set up the first appointment.
The First Visit
That Tuesday, I left work an hour early to beat the traffic. I called Mom from the car when I was about an hour away to let her know I’d be there soon, and so would Jenny.
“Now why’s she coming again?” Mom asked.
“She’s a nurse and she’s coming to make sure everything’s going okay with you,” I answered, momentarily flustered.
“But you know I’m doing fine,” Mom snapped. “I don’t know why I have to do this. I haven’t cleaned the house. I don’t want any company. Just take me out to eat.” I could hear the doubt and suspicion in her voice. “Was this your idea?”
“Actually, the doctor recommended it,” I said. “You know, Dr. Goldman.”
That seemed to do the trick — at least for the moment. I tried to quell my anxiety by listening to an audiobook as I drove. Still my mind wandered, and I wondered how this visit would go. What would we do if Jenny thought my mother wasn’t able to live safely by herself any longer? It seemed we had just taken it for granted all these years that Mom would live in her own home.
We hadn’t done much planning for the future, mostly because I was reluctant to discuss financial topics with her. She was a very private person. She hadn’t shared much with me about her finances, even after Dad had passed away five years earlier. They both had pensions from their employers as well as Social Security, but I wasn’t privy to the details. I knew they’d bought a long term care insurance policy years before, but I wasn’t sure if Mom had kept up with the premiums.
This made me think again about those bills I’d seen on her kitchen table. Maybe there was a subtle way I could bring up the topic once the care manager was there.
# # #
Jenny arrived right on time, just as Mom was ready to get into it with me again about why she had to “entertain a stranger.”
“Mrs. Spencer and Mrs. Grayson, I’m so happy to meet you,” Jenny said as she introduced herself. We ushered her into the living room and Mom motioned for her to sit on the couch. While we made small talk for a few minutes, Jenny removed a laptop from her bag and donned a pair of reading glasses.
“So, you’re here to see if I’m okay, is that right?” Mom asked, heaving herself into a chair across from Jenny. “Well, see? I’m okay! I know what year it is and who the President is.”
“There’s no fooling you, is there?” Jenny said, smiling. She gently began asking Mom questions, first about her health. When Mom paused to consider an answer, Jenny waited patiently and didn’t try to prompt or hurry her. She asked Mom to show her the medications she was taking. We had gathered the pill bottles earlier and Jenny looked at each one and typed on her keyboard.
“How do you remember when you’re supposed to take your medicines?” she asked Mom, who shrugged. “Have you ever used a pill box?”
“That would be a good idea,” I chimed in.
“You’re a pill.” Mom looked at me and laughed. “Always bothering me about something.”
That gave me the opening I needed. “Well, Mom, I am concerned that you might be forgetting things, like doctors’ appointments or paying your bills.”
“See? There she goes again,” Mom said, waving her hand at me.
“Can you tell me about that?” Jenny asked Mom. I had already filled her in about Mom missing her last medical visit. And with skill and diplomacy, worthy of a foreign ambassador, Jenny drew out that Mom had totally forgotten about her appointment. It wasn’t that she disliked the doctor or felt uncomfortable with him; she simply couldn’t remember to write down the appointment times.
“And I don’t answer the phone all the time,” Mom went on. “All those robo-calls, people trying to sell me things. So, I missed the reminder calls, I guess.”
Jenny went on to ask Mom about her social life and the home environment, including how often Mom ate, and how she managed with her activities of daily living: getting dressed, bathing, and so forth. She also asked how she did with cooking, cleaning, doing laundry, shopping, and managing her money. She asked Mom if she’d ever fallen, if she had grab bars in the bathroom and tub, and other safety related questions. Finally, she broached the topic of finances, and I learned that Mom thought she still had the long-term care policy that she and Dad had bought years earlier. I was hoping it wasn’t an unpaid bill on the table.
“I can show it to you and maybe you can figure it out,” Mom said to me. “Lots of small print in there. Remind me later.”
By the time the visit was over, Mom seemed fairly calm and offered to make Jenny a cup of tea. “I have that Earl Grey. You would like it.”
“Thank you so much, but I’m afraid I can’t stay,” Jenny said, as she closed her laptop. “I have a poodle at home and I have to let him out. I’ve been gone all day.”
“A poodle?” Mom perked up. “I had a poodle once a long time ago. A standard. What kind of poodle do you have?”
“Harley’s a standard poodle,” Jenny said. She smiled and shook her head. “He’s quite a character.”
“My Scruffy was too!” Mom said, and she pointed to a framed photo on the fireplace mantel. “See that picture? That’s Scruffy with the dish towel. He’d snatch it off the counter top and run all over the house with that towel.”
Boy, did I remember that. Mom and Dad had gotten Scruffy from a poodle rescue. He’d lived a long life, entertaining Mom and Dad to no end. It was their first and only dog and neither had any clue about how to train him, so he ran the house.
That led to an animated conversation about standard poodles and their mischievous nature. By the time Jenny had packed up her laptop, Mom was smiling and asking when she’d be visiting again.
# # #
I took Mom out to her favorite local diner for a light supper after Jenny left.
“Seems that you liked her?” I asked. “You wouldn’t mind if she comes over again or maybe even takes you to your doctors’ appointments?”
Mom nodded. “She’s a nice girl.”
When I got home, I told Bill what had transpired. “I really like her,” I said. “She seems very calm and patient. She knew how to handle Mom, and Mom liked her too. Maybe she can help us figure things out.”
“Sounds like you should hire her.” Bill said, and I agreed. “I’ll call her first thing in the morning.”
The Care Plan
Before I had a chance to call, Jenny called me the next morning.
“Angie, I’ll have a written report I can email to you with my recommendations,” she said. “But I wanted to go over my impressions with you, so you and your mother can decide on next steps.”
Jenny explained that she had concerns about my mother’s cognitive abilities and explained that Mom’s primary care doctor could do a more thorough exam and possibly rule out other causes, such as unstable blood glucose levels, depression, thyroid disease, or a urinary tract infection. “I’d also suggest that you consider some in-home care to help your mother with things like shopping, laundry, and preparing meals. I think she could benefit from more social interaction too. Since she can’t drive to the senior center anymore, she’s alone most of the time. That neighbor she mentioned, Nancy, really doesn’t seem to be that involved.”
I realized I had taken too many things for granted. Mom had given up her car keys a year earlier when she had a fender-bender in a parking lot, but she had reassured me that her neighbors were looking out for her and were giving her rides when she needed them. Maybe that was another reason she had missed her medical visits…. besides not remembering her appointment times, she didn’t always have transportation.
“I think she didn’t want to ask me to take her to the doctor,” I said, feeling a pang of guilt. “Because I live 2 hours away and I work full-time.”
“That’s possible,” Jenny said. “But we can look into different options for how she can get to her appointments.”
“And speaking of that, we do want to hire you to coordinate Mom’s care,” I said. “I looked through the paperwork you sent to me the other day and signed it.”
We talked some more, and Jenny suggested some practical tips such as getting Mom a pill box, so she wouldn’t forget to take her meds, and removing any throw rugs around the house that could be a tripping hazard. She also recommended that we review Mom’s long-term care insurance policy, so we would know that she has been paying the premiums and what kind of coverage she had so we could do some short and long-term planning.
“Do you think Mom should be in an assisted living facility?” I asked. “Is it safe for her to live at home if we do get someone in to help her out?”
“We can try it and see how it goes,” Jenny said. “In the meantime, let’s set up the appointment with her primary care doctor for a more thorough evaluation. And we’ll need to make sure she sees the cardiologist too.”
I hesitated. “Would you come with us?” “Of course,” Jenny said.
We talked about home care agencies and Jenny recommended a local company with a good reputation. “I’ve had excellent feedback from other families who’ve used their services. They provide professional development training for their staff and of course, they do a complete background check on the people they hire.”
“That’s good to know, because I’m worried about a stranger in Mom’s house,” I fretted. “I’ve heard some horror stories on the news. I want them to treat her well and I want to make sure they do what they’re supposed to and don’t sit around on their phone all day.”
“Absolutely,” Jenny said, and explained that she could keep an eye on the situation and monitor Mom’s care.
“That’s such a relief,” I said, meaning every word. “I’m really glad we have a plan.”
Of course, you know what they say about the ‘best-laid plans.’ The phone rang that evening after dinner while Bill and I were watching TV. I saw on the caller ID that it was Mom.
“Angie,” Mom said, when I picked up. Her voice was strained, and I could hear her breathing heavily. “I need help.”
“What happened?” Instantly, I was on high alert.
“I got dizzy and fell down. Oooh,” she moaned. “It hurts so bad.”
“All right, we’re going to get you an ambulance.” My hands were shaking as I motioned to Bill. “Stay on the phone with me, okay?”
While Bill dialed the police emergency number in Mom’s town, I tried to keep her talking.
“They’re sending an ambulance now,” Bill said, after speaking to a dispatcher. “They’re taking her to the Emergency Department at Brandenville Memorial.”
“Mom, we’ll meet you there, okay?” I looked at my watch. We couldn’t get there in less than 2 hours. I hated for Mom to be at the hospital alone.
“Why don’t we call Jenny, too?” Bill said. “She gave you her cell number, didn’t she? She can get there before we can.”
“Yes.” To my great relief, I reached Jenny on her cell right away and she agreed to meet Mom at the hospital.
# # #
Bill and I made it to the hospital 2 hours later. It was a busy night at Brandenville Memorial; the emergency room was packed with people. Mom and Jenny were nowhere to be seen. The receptionist at the front desk buzzed us in and a nurse guided us to a curtained cubicle.
My heart sank when I saw Mom lying on the hospital bed. She looked deathly pale.
Jenny rose to greet us. “Your mom has a fractured rib,” she said. “They did a chest X-ray a little while ago, and the doctor should be here shortly to talk with us.”
“Mom, how are you feeling?” I asked, bending closer to the bed.
Her eyes brimmed with tears. “It hurts to breathe. Why won’t the doctor come?” “They’ll be here soon,” I said. “Just try to relax for a few more minutes.”
“Angie, let’s step outside for a moment,” Jenny said, and I glanced at Bill. He nodded, and Jenny and I moved into the hallway.
“I have concerns about what led to your mom’s fall,” Jenny said. “She was very confused tonight, and she said when she got out of her chair to go to the kitchen, she felt dizzy and lost her balance. I’d like to speak to the doctor and really push for her to be admitted tonight, and not just be placed on observation status if they decide she should stay overnight, or even for a few days. It’s not just her rib. With her cardiac history and diabetes, she’s at a higher risk for a TIA, a mini-stroke, and I want them to do some tests and check that out. Her blood pressure’s been high tonight.”
“What does observation status mean? If she stays overnight, isn’t that the same thing as being admitted?” I was confused. “She’s on Medicare, so does it matter?”
“Yes, it does matter, especially if she needs skilled nursing care after this,” Jenny said. She explained that if Mom was in the hospital under “observation status,” even if she was there for three days, she was considered an outpatient and covered under different rules. Consequently, if she needed skilled nursing care after the hospital stay, Medicare wouldn’t cover it.
“I didn’t know that,” I said slowly. “I don’t have any experience with this.” At that moment, the doctor finally arrived.
Besides the fractured rib, Mom’s blood pressure fluctuated at dangerously high levels. An EKG also showed arrhythmia, which the doctor explained was common, and serious, in patients like Mom with congestive heart failure. He explained that when an elderly person had a rib fracture, there could be respiratory complications such as pneumonia. Moreover, people with diabetes were more vulnerable to infections.
Mom was admitted to the hospital and stayed for several days while the medical team managed her pain from the fractured rib, did tests, and got her stabilized. They ruled out a TIA, but Mom was still at risk for one due to her medical history.
I took time off from work to be with her and stayed in touch with Jenny every day. She was like a lifeline, reassuring me when I worried out loud, and staying positive. When Mom’s doctors recommended a stay in rehab, because Mom needed additional time to recover before she could go home, Jenny walked me through the process.
“They’re recommending their own rehab unit, of course, but you do have other options,” Jenny explained. “In my experience, she’ll be more comfortable and get better care at the skilled nursing facility a few miles away in Zale Springs. They have a very good reputation for senior care and their physical and occupational therapists are excellent.”
“Let’s try it then,” I said. I really had no idea who the best providers were.
Jenny was with me during the discharge process, when the medical team reviewed Mom’s medications. Some of her prescriptions were changed since there was a concern that her dizziness could have been caused by her high blood pressure medication.
Jenny advised me that even though the hospital would be sending Mom’s medical information and medication regime to the skilled nursing facility, it was always a good idea to have a list, or medication management form, and make sure it reconciled with the medications provided.
By now, Mom was more than ready to leave the hospital. Jenny arranged for the transport to the nursing facility and we got Mom settled in. She had a roommate named Sally, a cheerful woman in her eighties who was recovering from a broken hip.
“Guess I’m not going to be running any more marathons,” Sally said to Mom. “At least, not this year.”
I learned a lot about rehab, care plans, and Medicare during Mom’s stay at the facility. I had to return to work and couldn’t visit every day, but Jenny relayed any questions I had to the care team. She dropped in often to check on Mom and kept me informed about her treatment and progress. She attended the care plan review meetings and made sure that Medicare would continue covering mom’s recovery.
“In some areas she’s doing well,” Jenny reported one afternoon, two weeks after Mom had been admitted. “She’s eating better, her blood pressure is under control, and she’s more alert. But she’s still weak, and she’s not improving as much as expected with physical therapy. She doesn’t like it much, and she’s not working that hard on the exercises that will increase her strength and improve her balance. Sometimes she just wants to stay in bed, but that’s not good for her.”
Besides physical therapy (PT) for Mom to increase her mobility, she was being taught how to shift between her bed and chair without further injuring her rib. She was also practicing deep breathing to avoid pneumonia. It would take at least six weeks for her to heal.
Medicare was covering Mom’s stay, and she was entitled to up to 100 days in the nursing facility, with the first 20 covered 100%. But as Jenny explained, the rules were stringent. The best case scenario was for Mom to achieve a higher level of functioning before her discharge.
“Even though Medicare will pay for so-called maintenance therapy, if the patient’s functional abilities will deteriorate without those services, I often have to be a strong advocate for the family,” Jenny told me. “Some health care providers incorrectly tell people that Medicare won’t pay for rehab unless the patient shows continued improvement. We’re better off if we don’t have to get into that battle.”
I hadn’t known anything about the ins and outs of Medicare, but I was learning fast. What a maze of rules and regulations! It was such a relief to have someone on our side who knew the system and could navigate us through it.
# # #
Fortunately, Mom’s roommate, Sally, turned out to be Mom’s cheerleader whenever she felt tired or discouraged.
“You can do it,” Sally said, when Mom complained it was time for PT again. “Keep your chin up. You got this, girl!”
Mom would roll her eyes, but with Sally and Jenny’s encouragement, eventually she did make more of an effort with her physical therapy. We had several conversations with her care team about a discharge plan.
Mom wasn’t interested in considering assisted living. “I’m not ready to live with a bunch of old people. I want to go home,” she said. Her wishes were clear, so our next steps were determining what she needed to live at home safely.
The good news was, we noticed that the changes with Mom’s medications seemed to make a big difference in her cognitive abilities. She wasn’t as confused as she’d been before her fall, and she was social with other patients.
“Have you noticed that your mom has really come out of her shell?” Jenny asked me. “Even though she wants to live at home, she’ll do much better if she isn’t alone so much. It’s important for seniors to have social connections. No matter how old we get, we still need other people.”
We had reviewed Mom’s long-term care policy as well as the coverage allowed by Medicare for home health services. The agency that Jenny had recommended before Mom’s hospitalization still seemed like the right fit.
Mom was ready to go home. She would still need PT to work on her balance, which could be done on an outpatient basis and she needed help with the activities of daily living.
“I’ll arrange for your mother to have an interview with the agency’s home health aide,” Jenny said. “We want to make sure it’s a good match, and she’s comfortable. We’ll want the aide to help her with dressing, bathing, meals, and to make sure she takes her meds.”
We lucked out; Mom instantly liked the woman the agency sent to the interview. Sasha was a gregarious older lady with a friendly smile and easy manner. She was a Certified Nursing Assistant (CNA) with more than twenty years of experience working with seniors.
“Do you like to play cards?” Mom asked her during their meeting. “You ever play Chinese rummy?”
“Oh sure,” Sasha said. “Chinese rummy, setback, poker, you name it.”
Mom smiled with satisfaction. “Good. Maybe we’ll get along then. You play bingo too? Would you take me to the senior center to play bingo on Saturday afternoons?”
# # #
A couple of days before Mom was discharged from rehab, Jenny suggested that we take a tour of Mom’s house, before she came home, to address any safety concerns.
It was the weekend and Dana and Alex came along to help spiff up the house inside and out. We got rid of the throw rugs that were a tripping hazard and cleared away the clutter. In addition, Bill installed grab bars in the bathroom. The last thing Mom needed was to have another fall.
“I would also advise that you get a medical alert device she can wear,” Jenny said. “That way, she can get immediate help in an emergency.”
Mom had resisted this idea before, but after the fall and being away from her home, she was agreeable.
“If it makes you happy and I can stay at home, I’ll do it,” she said. “I don’t want to be like the lady in the commercial who falls and can’t get up!”
Once Mom was home again with her support in place, I went back to my full-time work schedule. While there was no guarantee we wouldn’t have another crisis, I could sleep easier at night knowing Mom wasn’t always alone.
We asked Jenny to drop in once a week to check on Mom and make sure she was getting good care and was happy with Sasha, the CNA from the home care agency.
Sasha came five days a week for 4 hours each time. She helped Mom bathe and dress, made her breakfast, did laundry, and cleaned up the house. She had her own car and once a week, she took Mom to the grocery store. We could have ordered groceries to be delivered, but Mom enjoyed getting out and running errands.
I visited one weekend a month and made sure to take her to Bingo when I came on Saturday. Fortunately, Mom’s rib healed without her developing any respiratory problems or infections. She had physical therapy twice a week, but it was difficult for me to take time off to accompany her. I wanted to make sure Mom never missed her scheduled appointments, so we asked Jenny to take Mom to PT and to her other medical providers. Jenny called me after each visit to let me know how things were going and always kept me in the loop.
At one point, Sasha had a family emergency and needed two weeks off. The agency reassured us that they would send someone just as qualified as Sasha to fill in, but I was nervous about a new aide coming in who wasn’t familiar with Mom and her routine.
I called Jenny for advice. “Do you think you can be there on her first day to make sure everything’s going okay?”
“Absolutely,” Jenny said. She spent an hour or so with the new person, Meghan, to introduce her to Mom and orient her to her temporary assignment. Later that day she called me.
“Angie, Meghan seems like a nice young woman and experienced enough, but your mother is upset by the change. She told me when I left that she didn’t want Meghan to come back. Would you like me to talk with her about it and see if we can resolve it?”
“Sure,” I said, feeling a little flash of impatience. Mom wasn’t always that easy to please, and she’d gotten used to Sasha. What if she didn’t like anyone else that the agency sent?
“Can you let me know what happens? What are the options if she’s stubborn about it?”
“I can contact the agency and ask them to send someone else,” Jenny said calmly. “But first let’s see what happens.”
# # #
It turned out that Mom didn’t like Meghan mostly because she thought Meghan was “too young and wore too much make-up” – and mainly, because she wasn’t Sasha. After Jenny talked with her and convinced her to give Meghan a chance, Mom agreed she could come back the next day.
“It’s not easy to have a stranger in your home, helping you bathe and get dressed,” Jenny reminded me when we talked on the phone. “Remember, your mom wasn’t all that keen on Sasha when she first arrived. It took her a little time. It’s normal that she’s upset about the change, even if it is just temporary.”
Jenny’s words struck a chord with me. How would I feel if I was frail and needed help from someone I didn’t know? I would be wary too. I would probably be even more resistant than Mom.
We knew, that with each passing month and year, Mom’s health was likely to decline. Her chronic medical conditions could result in another hospitalization at some point. She had part-time home care services now, but we had to think about the future.
There might very well come a time when Mom couldn’t stay at home, even with people hired to help. And while she was mentally competent, it was important for us know about her heath care wishes and get it legally in writing. It was hard for us to think about, much less discuss openly and honestly. Jenny pointed out we were so much better off to plan in advance rather than scramble during a crisis. I wanted to include my brother in Singapore so during a Skype call he weighed in with his opinion.
“Obviously there’s not much I can do on my end, but if you need financial help for Mom, just let me know,” he said. “I’ll help out as much as I can.”
Surprisingly, having the conversation with Mom about these important matters was less difficult than I thought.
“I guess it’s about time we talked about this,” Mom said. “Just in case I don’t outlive you!”
Jenny referred us to an elder law attorney, and we had an appointment with her a few weeks later. Mom already had a will that she and Dad had prepared years earlier, but it needed to be updated. Mom also signed off on the documents for advance directives. The attorney gave us a primer on Medicare and Medicaid, and the options we had if Mom couldn’t live at home. Her long-term care insurance was covering her home care services right now and would pay a percentage of nursing home care if she needed it, but only for a certain period of time.
“I guess we just take things day by day,” I said to Bill. “But at least I don’t feel like I’m flailing around anymore.”
The Aging Journey – Six Months Later
Predictably, Mom has had her ups and downs. A few months after she came home from the rehab facility, she had a complicated urinary tract infection that resulted in another brief hospitalization. The infection affected her memory and we thought for sure she was losing her cognitive abilities. Fortunately, the antibiotic treatment for the UTI improved her symptoms and her mind became clear and focused again.
However, she’s gotten frailer and while she can still get around with a walker, it’s becoming more evident that soon she’ll need increased care.
We started looking at assisted living facilities, and her name is on a list now for one that she visited a few weeks ago and liked very much.
Jenny still monitors Mom’s care and brings her to her medical appointments when we can’t. She makes sure Mom’s doctors are aware of her treatments and medications so they’re all on the same page. In fact, she was the one who spotted the signs of Mom’s UTI and got her diagnosed and treated before the infection could turn to sepsis or damage her kidneys.
We’ve gotten to know each other so well, it’s like she’s a member of the family. A very helpful member of the family who knows senior care inside and out! We know we can consult with her whenever we need to, and when the time comes that Mom can’t stay at home, Jenny is prepared to assist us with the transition. Even after the transition to assisted living, we will continue to work with Jenny to make sure that Mom is getting the highest quality of care and living the best life possible. Having a care manager is an integral part of the aging process and having their professional expertise available is priceless.
One thing you can be sure of – life is filled with transitions. But for now – we take it one day at a time.
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This true-to-life story is presented by Senior Transitions of Tallahassee, Florida.
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