How can you improve the coordination of care for elderly patients as a case manager?

1 Assess the patient's needs and preferences

The first step in coordinating care for elderly patients is to conduct a comprehensive assessment of their physical, mental, social, and functional status, as well as their goals, preferences, and values. This will help you identify their strengths, needs, risks, and challenges, and tailor a care plan that meets their individual needs and wishes. You can use standardized tools and instruments to assess the patient's level of frailty, cognitive impairment, depression, pain, nutrition, mobility, and other factors that affect their health and well-being. You should also involve the patient and their family or caregivers in the assessment process, and respect their choices and autonomy.

3 Manage transitions of care

One of the most critical aspects of coordinating care for elderly patients is managing transitions of care, which are the movements of patients between different settings, such as hospitals, nursing homes, home health agencies, and community services. Transitions of care can be challenging and risky for elderly patients, as they may experience changes in their health status, medications, providers, and care plans. As a case manager, you need to ensure that transitions of care are smooth, safe, and timely, and that the patient receives the appropriate level and continuity of care. You can do this by following best practices and standards for care transitions, such as using checklists, discharge summaries, medication reconciliation, follow-up appointments, and post-discharge phone calls.

4 Coordinate resources and services

Another important aspect of coordinating care for elderly patients is coordinating resources and services that can help them maintain or improve their health and quality of life. These resources and services may include medical equipment, assistive devices, home modifications, transportation, meals, personal care, respite care, legal assistance, financial assistance, and other community-based programs. As a case manager, you need to identify the resources and services that the patient needs and is eligible for, and help them access and utilize them. You can do this by providing referrals, advocacy, navigation, and follow-up. You should also evaluate the effectiveness and satisfaction of the resources and services, and adjust them as needed.

5 Promote self-management and empowerment

The ultimate goal of coordinating care for elderly patients is to promote their self-management and empowerment, which means enabling them to manage their own health and care, and participate in decision-making. Self-management and empowerment can improve the patient's outcomes, satisfaction, and quality of life, as well as reduce the need for costly and unnecessary services. As a case manager, you can promote self-management and empowerment by providing the patient with education, coaching, feedback, and tools that can help them understand their health condition, monitor their symptoms, adhere to their care plan, cope with their emotions, and communicate with their care team. You should also encourage and support the patient's self-efficacy, motivation, and confidence.

6 Learn and improve your skills and knowledge

The last strategy to improve the coordination of care for elderly patients is to learn and improve your own skills and knowledge as a case manager. Coordinating care for elderly patients is a complex and dynamic task that requires constant learning and improvement. You can learn and improve your skills and knowledge by seeking feedback, participating in training and education, joining professional associations and networks, reading journals and publications, and attending conferences and workshops. You should also keep up with the latest trends, innovations, and best practices in case management and geriatric care, and apply them to your practice.