Coordinating Medical Care VNA Community Healthcare A Guide for Family Caregivers VNA Community Healthcare

Agenda for this Session What is good care coordination? Organize medical care Be an advocate Coordinate care

What is Care Coordination? Organizing medical care activities and information to get the best possible health results for the person you are helping.

Care Coordination Challenges We will go around the room and introduce ourselves In one minute or less, describe one care coordination challenge that you have faced

Care Coordination Steps Organize Advocate Coordinate

Organize to Stay Sane DO THIS NOT THIS

Organizing Steps Navigate the health system Keep track of medical information Manage your insurance Maintain medication lists and refills Plan ahead with advance directives

Navigate the Health System Use your primary care doctor for most things Specialists for complicated illnesses Save the ER for real emergencies Always check insurance

Things You Should Track Appointments Provider contact info Test results Internet passwords Insurance paperwork Visit notes Medications

Organization Tips and Tools Exercise Look at the care coordination tools on the table Pick some that might work for you Discuss other tools you use and organizing tips Be prepared to recommend 3 good tips or tools

Find Reliable Resources Federal and state agencies UCONN personalized health information research program 211 for community resources Consumer Reports Choosing Wisely Agencies on Aging On the internet – look for reliable sites

Manage Your Insurance Show Your newest card Get required approvals Track copays and deductibles Check travel rules Use participating providers Use plan discounts Learn the appeals process Use nurse lines for advice Read the coverage list Participate in disease management programs

Keep medication lists updated Organize meds in one place Manage Medications Keep medication lists updated Organize meds in one place NO Keep up with refills

Have the Hard Conversation Living will Health care agent Healt Will Finances Resuscitation Care choices

Advocate Go to all medical visits with your relative Make a list of health concerns Bring current medical information Ask good questions Write down instructions

Put Yourself in Charge Video Watch the video How did the communication go? What worked? What didn’t work well? Are there ways you might be able to improve your up two way communication with medical professionals?

Medical Communication Tips Set the stage Be clear about what you want Ask “what if” questions Ask questions about medical findings and treatment choices Clarify instructions before you leave

Did You Get What You Need? Think about the last medical visit or phone call Did you get what you wanted? Did you ask the right kind of questions? Did you get the information you needed? What could you do differently the next time?

Coordinating Your Job as a Caregiver

How Often Do You Think This Happens? Medical professionals communicating about a case.

Not So Much

The Essence of Care Coordination Information flows with the patient Professionals communicate Nothing falls through the cracks

Fall Through the Cracks Brainstorm Brainstorm a list of situations where you have seen medical things “fall through the cracks” Discuss how you can be the “glue” that keeps care and information coordinated

Your Job is to Be the Glue High Risk Situations Hospital Admission Shift or doctor changes in the hospital Hospital or nursing home discharge After a medical procedure or one day surgery Discharge from home health care Multiple “care coordinators” calling

Care Coordination Sample Script Dr. Jones, my husband has a number of doctors and you don’t all seem to be communicating with each other. We have had several instances of duplicate medications being prescribed. Would it be possible for you to call or write a note to his primary care doctor and nephrologist? If you have access to the hospital online record, could you please check to see what other doctors have prescribed?

Coordinate Care Coordinators If you get a call from a “care coordinator”: Write his/her name and phone number Ask what organization they represent Find out why they are calling Find out how they can help you. If they can’t, politely refuse to talk, if you don’t want to

Balancing Act Write down 3 strategies that you use to balance your life as a caregiver

Caregiver Survival Rules Care for your own health Get an outside perspective Ask for help Rest Laugh Join a support group Focus on accomplishments

Helpful Information What information provided today do you feel you can put into action when you get home? What are some of the things that still concern you?

Thank You! Questions? Guilford office: 203.458.4200 Hamden office: 203.288.1623