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Sample Care Manager Visit Notes/Family Updates

What follows is an example of some exchanges our care manager had with regard to in-home care for a client.

Case Notes from Care Manager to Home Care Givers:

Nancy,

Here are the changes and concerns for Joe Smith.

First we believe that Joe is requiring more hours which is a big part of some of the issues. The family would like to increase the hours to reflect 3 hours in the morning from

Hours: 8:30 AM – 11:30 AM and the afternoon to remain the same from 7:00 PM – 9:00 PM

Meals: We are requesting that the caregivers go back to preparing the meals from Joe. Betty (Joe’s wife) is not preparing the meals for Joe to the level of nutrition that he requires and the caregivers need to get back to doing this whether Betty tell them not to worry about it or not. Joe’s daughter and son will make sure there are groceries to prepare these meals.

Cancellations: Betty is in the habit of cancelling the caregiver. This is a big concern. The couple’s daughter, Julie Smith, agent under the POA and wants to insure that Joe receives the care and oversight he needs, even if Betty does not recognize the need for this service. Per our prior conversation, Betty cancels your service frequently for several reasons. If Betty calls your agency to cancel or change a caregiver’s schedule, please call Julie Smith, Ben Smith, as well as my cell number (208-355-5555) immediately to confirm that this is ok. Joe has fallen several times at home in the last couple weeks, as you know, and my investigation reveals this occurred while he was alone.

Medicaid: Can you please work to request more Medicaid reimbursed hours? They met with Dr. Heart today and she agrees Joe needs more care at home than he is getting.

Medications: Betty is not giving Joe’s medications to him on time, or even the right pills. They have a medication dispenser that his family fills and she keeps taking the lid off. Betty believes that Joe can take his pills on his own. They end up on the floor and all over the counter. Joe is not able to pick them up and is not getting some of them. Please have your caregiver give the medications to Joe directly from the dispenser:

Upon arriving at 8:30 AM

Before leaving at 11:30 AM

Afternoon shift: at 8:00 PM

As I stated the other day, Joe is currently not doing well at home. He is left to go outside on his own unsupervised, he is falling, he is not getting his meds on time, and he is not getting proper nutrition. We need your caregivers to be able to go in and know what the plan is for the day without having to take direction from Betty. Often they come in and stand next to Betty waiting for direction and she will not be able to provide it. They need to work off the care plan that I have provided and know what the routine is for the day. Betty is very easy to get along with and often distracts caregivers. We need someone who is self-directing and can take care of Joe.

Please give me your feedback on these issues right away. We’d like you to increase the hours by this coming Monday. I look forward to hearing from you!


Notes from Home Care Givers to Care Manager:

Rebecca,

I have updated the schedule as of today. However, I noticed that your email said that they want the evenings to stay the same 7-9pm. They currently have a schedule of 6:30-8:00pm. Do we need to change this?

I am meeting with the caregiver today to address the concerns. I am going to be quite direct regarding policies and procedures regarding scheduling, care plans, and self-direction. I will review each of the concerns and a plan of action to address them. I am also scheduling our RN to meet with Mr. and Mrs. Smith for an assessment. At that time, we can submit a change in hours request to Medicaid. We will also take that opportunity to review the care plan and schedule with Betty.


Notes from Care Manager to Home Care Givers:

Nancy,

Thanks for the update. Please keep the evening times the same. I just want to make sure he gets his medication before they leave.

Also, will you let me know when the RN plans to go out and assess? I arranged to be there today and understand it needed to be changed.

Thanks for all you are doing to help insure Joe stays safe at home. Betty complained to Dr. Heart that she needed more hours to help take care of Joe, however she has been cancelling with your agency. Are you and your staff on the same page with the family and me that the cancellations need to come from either the daughter or me to help prevent unnecessary changes?


Notes from Home Watch Care Givers to Care Manager:

Rebecca,

I spoke with the primary caregiver today. I was quite clear about our concerns and Joe’s unmet needs. I addressed meal preparation, medication reminders, working of the care plan with self-direction, and that ALL scheduling changes are to be directed to the office so that we can call the daughter or you. I talked about separating her personal feelings from her professional job. We talked about how easy it is to become friendly with a client or their family and that it needs to not interfere with the Client’s care and needs.

Our caregiver assured me that from now on she will personally call us if Betty is trying to change the schedule. She will also begin preparing meals in advance for the time that she is not scheduled to be there. She is going to encourage Joe to accompany on walks more often.

I will let you know as soon as we schedule our RN to do the assessment.


Notes from Care Manager to Family:

Julie,

I am not sure if you already know, the meeting with Home Caregivers has been cancelled. It will be rescheduled for Tuesday or Wednesday and I have contacted the agency and requested they keep me in the loop for the time and day.

Also, I have requested an order from Dr. Heart’s office for Home Health as we discussed at out meeting as follows: RN for medication management, PT related to recent falls, OT for bladder retraining.

I will keep in touch on how these issues are going. The caregiver agency is sitting down with the caregiver today and is reviewing the list of concerns we have with care and the appropriateness of staying PROFESSIONAL at all times while on the clock.

Let me know if anything else comes up. They are also starting the increased hours right away and will be requesting more hours from Medicaid as soon as they can get the nurse out for the evaluation.


Notes from Family to Care Manger:

Thanks Rebecca for the update. Do you think that Ben or I should be at this meeting with the caregivers?

Ben and I spoke with Betty and Joe on Sunday about the changes we discussed for dad. My mother is resisting having the responsibility of the meds taken away from her and adding more hours throughout the day. She doesn’t want a care giver in the house during the evening hours at all and insists that she can give dad his meds in the evening. Ben and I explained that this is the type of care that dad needs now and we want to reduce the burden on her since my dad’s needs for care will be increasing. Ben and I were very adamant that the changes need to happen and it is in the best interest for dad.

Ben and I do see that we need to be more actively involved in the decisions and structuring of our dad’s care so we will make a point to be included in the future.