What is a Care Coordinator?

Mom is starting to fall frequently.  Dad’s Alzheimer’s has progressed, and he is beginning to wander out of the home.  Grandma has suffered a stroke and needs rehab – or may need long-term care.  Grandpa is overwhelmed by the Medicaid assessment process.  You want to pick up the phone and call for help – but what type of professional can address all these challenges?A care coordinator may be the best person to answer pressing questions about your or your elder loved one’s care needs. There are lots of elder care providers out there – residential facility staff, in-home care agencies, Alzheimer’s organizations, transportation companies, support groups, and hospital staff, to name a few. But you don’t always know where to start or which services will be most appropriate for your situation. A care coordinator can evaluate the circumstances, make recommendations, and connect you with the resources in your community that will best serve your needs – both in the short-term and over a longer period of time.“A care coordinator is the hub of the caregiving wheel,” says Jill Shoffner, LCSW, Care Coordinator at Elder Law of East Tennessee. “We have our eye on the big picture regarding the best options for our clients. We can advocate for and assist with implementation of an overall plan that will take into consideration the elder’s goals and values, as well as the strengths of family caregivers. We want to be the person contacted to get resolution to any caregiving issues.”Care coordination is one of the services that sets Elder Law of East Tennessee apart from conventional elder law firms. Our full-time staff includes a licensed clinical social worker, a registered nurse, and a gerontologist who use a biopsychosocial approach to achieve a positive outcome for our clients. But what does care coordination have to do with the practice of elder law?Elder law is just one piece of a much bigger puzzle:  the successful aging puzzle. Traditionally, elder law encompasses legal documents needed as a person approaches the end of life and after their death. It may also include asset protection strategies. The traditional elder law focus is on preservation of wealth and the legal “nitty gritty” of decision-making. In contrast, we believe the best financial and decision-making strategies are developed from a “care first” perspective. How will the person’s care needs change as they age? What is the expected cost of care? What if the healthier spouse takes a sudden turn and becomes the spouse in greater need of care? What if the primary caregiver becomes unavailable? What resources are available to help pay for care? Only by exploring such questions can the legal team determine the best approach for using family resources and establishing a decision-making chain of command.“There are so many aspects related to successful aging, and all of them need to be addressed and coordinated because they are all intertwined,” says Care Coordinator Kyra Clements, Gerontologist.  According to Functional Performance in Older Adults, this includes physical, emotional, spiritual, legal, and socio-economic factors that influence the aging experience. “One factor can have profound effects on the others,” says Kyra.  “There are many legal documents, procedures, and processes that must be followed to achieve the optimum care outcome.  This involves precise coordination among everyone involved, including family members, care providers, agencies, facilities, etc.”The care coordinator’s primary responsibility is to function as the advocate for the elder adult or person with disability.  “We take time to learn their life story, values, and goals, and we advocate on their behalf,” says Kyra.  “We provide a holistic approach to care needs, incorporating the physical, emotional, and spiritual needs of the individual.”  And, she explains, care coordination services extend beyond the family member most obviously in need of care.  “We provide this same approach and support to caregivers, who are often overwhelmed, exhausted, and sometimes unsure about what they need and where to go to receive appropriate support.  We identify what resources and services are needed, and we guide the family through the process of obtaining them.”Every day for a care coordinator is different.  Some days involve addressing financial issues with insurance companies.  Some may deal with helping to navigate complex family dynamics, assisting with a Medicaid application, searching for placement options, or looking for assistive technology devices that can help someone stay in their home safely. Some days the care coordinator addresses daily care needs, individual fears and concerns, and acute crises.  Other days she refills a bird feeder for a resident in a facility, investigates new treatments for a medical condition, or sends a “thinking of you” card to brighten someone’s day after a difficult time.“It involves life,” says Kyra, “and that encompasses a variety of tasks.  Our goal is to provide the absolute best care and quality of life an individual can have, and that varies depending on the person and the circumstance. But quality of care and quality of life are always the foremost goal.” Photo:  ELET Care Coordinator Cindy Hutson, RN, meets with a couple to discuss future care needs.