By Jennifer Gazda DSW, LCSW, MSW
In any number of medical settings, case managers are faced with many demands including the need to coordinate complex care, support patients and their families, plan safe discharges, prevent readmissions, and address crises—all while balancing heavy caseloads and limited time. That’s where an Aging Life Care Association (ALCA) member, commonly known as an Aging Life Care Professional, can become an invaluable partner.
These professionals specialize in the aging journey and bring a unique combination of clinical knowledge, family systems expertise, care coordination, advocacy, and long-term planning. They help bridge the gap between what happens in a medical setting and what happens after a patient is discharged. Some Aging Life Care Professionals also specialize in additional areas outside of aging, including but not limited to behavioral health and developmental disabilities.
Let’s explore how these professionals could be the missing part of your puzzle.
Navigating Safe, Realistic Discharges
The patient is ready to be discharged medically, but you have seen this patient a time or two already due to lack of support at home or lack of follow through on the treatment plan. Aging Life Care Professionals can help with evaluating home safety and ensure that in-home care, transportation, or any other needs are arranged for to improve successful discharges. If the patient returns home and is observed to be unsafe during a visit, the Aging Life Care Professional can coordinate and support the patient through a transition to any needed level of care including but not limited to assisted living, memory care or skilled care. These professionals also help patients and their families understand what their insurance may or may not cover and can help to maximize their benefits.
For hospital and facility case managers, this means a trusted partner can continue supporting the patient long after discharging from the medical setting.
Advocacy and Coordination of Care
Patients often struggle with maintaining adherence to their medical treatment plan or may become overwhelmed by the volume of what they need to remember. Older adults may have multiple specialists, changing medications, cognitive decline, and conflicting recommendations. Have you ever attended an appointment with someone who then shares a summary of what happened but they left out some key details? This is where an Aging Life Care Professional can shine as an advocate.
Aging Life Care Professionals are commonly sought after to attend physician appointments, ensuring to ask questions and details of the patient’s condition are shared with the provider. They further facilitate communication amongst providers to ensure continuity of care, and always ensure that the patient’s autonomy in decision-making comes first.
When several professionals are involved, Aging Life Care Professionals often become the key in keeping everyone informed and aligned.
Facilitating Difficult Family Conversations
If you have worked as a medical case manager for any period of time, it is likely you have been faced with a patient whose medical care is not nearly as complex as the family dynamics. Whether it be adult children of an aging parent disagreement or a spouse that is in denial of treatment outcomes, poor family dynamics can have a great impact on the successful outcomes for a patient.
As an Aging Life Care Professional, we are skilled at remaining objective and leading discussions with compassion and empathy. We often are sought out to help families navigate an older adult’s capacity, safety in independent living, transitions to higher levels of care or, very commonly, the need to stop driving. As a neutral party to the situation, Aging Life Care Professionals are able to provide sound recommendations without the emotional reactivity that families often experience, and can remain involved with the family throughout the journey at any time for additional consultation.
Crisis Intervention When Things Fall Apart
Even with the best of plans and in the best circumstances, crises do arise. A patient may be prone to falls or wandering, and even with safeguards in place they may continue to be at risk. Aging Life Care Professionals are often called when families are in crisis and a plan is needed quickly to stabilize the situation. Often, families share that they wished they would have called sooner for the assistance following these situations as navigating the aging journey can be quite complicated for families. Support in a crisis can look like showing up at the ED with the patient to provide advocacy and support when the family can not be present, ensuring a caregiver can be located and placed in the home for safety, or connecting families to legal or financial resources for support.
Key Knowledge Areas
Members of the Aging Life Care Association often have backgrounds in social work, nursing, gerontology, or a variety of other areas of education and training. There are 8 key knowledge areas held by Aging Life Care Professionals:
- Health and Disability
- Financial
- Housing
- Families
- Local Resources
- Advocacy
- Legal
- Crisis Intervention
How to Find an Aging Life Care Professional
Families, healthcare providers, and case managers can locate a qualified professional through the Aging Life Care Association online directory at https://www.aginglifecare.org/
For healthcare teams looking to strengthen discharge planning and community support, building relationships with local Aging Life Care Professionals can be impactful for the successful outcomes of your patients.
Dr. Jennifer Gazda is Director of Care Management and Integrated Services for Arosa, a provider of home care and care management services throughout the United States. Jennifer Gazda has over 20 years of experience as a social worker in the Chicagoland area. Jennifer currently serves on the Editorial Board for CMSA, as well as a Director for the Chicago Chapter. Jennifer is on the board for the National Association of Social Workers - IL Chapter. She also is a board member for the Midwest Chapter of the Aging Life Care Association, and Unit Leader for the Illinois unit.