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Bringing in The Team (Part 1)

Having a family doctor involved in our home and hospital care has been important to most people for their whole lives but it becomes much more important to them as they age. But it’s no secret that a lot of us are still having trouble finding a family doctor and that there are ridiculously long waiting list to see many of the specialist we are referred to. Tests and scans take weeks, if not months, which adds to both anxiety and frustration levels for both the patient and the family caregiver.

Across the country, in rural and urban settings and in all demographic areas, primary care physician shortages have been acknowledged. A trend towards smaller practice sizes and less clinic patient visits being handled each month per physician has been a contributing factor. And, research shows that older physicians and some female physicians are also more likely to be involved in part-time work arrangements, restrict their practices to see certain types of patients and/or only do certain types of activities.

On the good news side, recent changes have opened up access to clinical nurse practitioners, pharmacists and occupational therapists who are now able to take on certain responsibilities to ease the burden on the doctors.

So, as you tackle the need for the best care for yourself or others, let’s get to know the players. Working through the maze of specialists, health care professionals, and social services is tough. Whose help should you seek when? Who should you contact first in a given situation? Here is a brief overview of some of the cast of thousands you’re likely to encounter as you make your way through the world of eldercare.

If Surgery is in the Cards 

Make sure that your elder’s family doctor and the surgeon agree on what is to be done and what the longer-term prognosis will be. There will usually be pre-surgery tests and visits with different specialists as well as education sessions that you’ll be invited to. Sometimes it’s confusing to figure out what each appointment is for and how long it will take, so don’t be afraid to ask for clarifications ahead of time. Although this preparation is tiring and time consuming, it’s worth it weight in gold when it comes to careful preparation on behalf of the health care team, and you and your family knowing what to expect.

After surgery there is often a disconnect between the family doctor and the hospital specialist making after-care at home more of a challenge than it needs to be. Personally, I feel for family doctors who suddenly get rather ill or recovering patients back into their ballpark with little information or background.

You, as a family caregiver, can prevent this by keeping good records and making sure that everyone is in the loop as things happen and conditions change. Even simple e-mails with updates are more effective and faster than system paperwork in most cases. Warn the doctor yourself before you attempt to bring a loved one home. Remember the doctor’s office might be the first person you need to call for help, so its best to bring them up to speed ahead of time.

Discharge planners or caseworkers from the hospital are the best people to help you get “take-home” instructions and paperwork to carry with you if it doesn’t come easily from the nursing team on the floor. Expect a family meeting to make arrangements and provide you with details about homecare arrangements. Make sure you get numbers of who to call when you get home…. Never take a wait and see approach. (In my case it took 3 days for someone to show up from homecare. By then mum was actually back in the hospital and getting ready to be admitted to long term care.

Palliative Care and the Family Doctor

As the team leader, the family doctor is in charge of a person’s medical care. He or she works closely with the person; family and palliative home care team to optimize patient comfort and care.

Expect the family doctor you choose to have someone on call 24 house a day and to make home visits when the person you are caring for is too sick to leave the house or residence. If necessary the team has direct access to a hospice care, the ability to admit to a palliative care unit of a hospital and to arrange for social work or counseling support for both the patient and caregiving family members.

Men and Doctor Avoidance
Males, especially those who are not married tend to access medical services less often than females. As a result, they tend to have poor health outcomes including death from heart attacks.

According to research one study found that non-married men also tended to seek routine physical exams less often than their female counterparts. One could speculate that wives tend to badger their husbands into seeking medical care. Or one could argue that married men have more at stake and take their health more seriously.

Another study of men admitted to the hospital for heart attacks showed that less than half of them called for an ambulance right away. Some felt that their symptoms weren’t that serious. The study authors speculate that others wanted to avoid the potentially embarrassing ride in an ambulance.

The Expanding Role of the Pharmacist

Pharmacists are trained in and study much of the same material as doctors in medical school. In fact, as it seems, the role of the pharmacist is just as important as the doctor and they can be just as helpful.

Pharmacist can give you information regarding medication, it’s side effects, interactions with other medications, and how to take prescription and non-prescription medication and suggest ways to remember and check side effects. Remind yourself to take proper doses.

Pharmacists are the drug therapy experts of the health care team. Their role in the healthcare system has changed significantly over the past few years, particularly with the expansion of their scope of practice, which allows the pharmacist to focus on the clinical aspects of direct patient care.

While pharmacists are still responsible for managing the overall pharmacy environment and overseeing dispensing, they now focus more on reviewing prescriptions for therapeutic appropriateness, performing medication reconciliation and medication reviews, developing care plans and monitoring patients.

The care plan is often focused on taking steps to resolve or prevent drug-related or health-related problems. Depending on the province or territory, the pharmacist may accomplish this by performing expanded scope activities such as adaptation of prescriptions, prescribing for minor ailments, ordering and/or interpreting laboratory tests and administering drugs, including injections for immunization or other purposes.

When it comes to planning home care or care in general for your loved ones, it’s always good to get a second view on it. While your doctor is trustworthy, your pharmacist may also give you insight or other useful ideas that you can use to better care that you didn’t realize before.

Adult Day Centres

These innovative centres are the geriatric equivalent of a child care centre. They provide stimulating social activities, nutritious lunches, transportation to doctor’s appointments and cost-effective, individualized nursing care for adults who need day-time supervision.

An alternative to paying for full-time home care, adult day programs allow families to keep their relatives actively engaged in an ‘out of the house’ community program. Ideal for family members who may be socially isolated or depressed, frail, confused, or suffering from dementia and/or those who are dependent on you for care.

Family caregivers can help staff by providing a mini-biography and an early photograph of the care receiver.

There’s may be an initial reluctance with getting older adults to attend and there may also be a dreadful feeling of guilt felt by the child who is doing the dropping off. Our take: Drop mum off in the morning with a smile on your face and go about you daily business. Just like your kids, she’ll probably been fine and active shortly after you’ve turned the corner.

Some members settle into the program more easily than others. For example, people who were “joiners” throughout their lives take to the program routine more easily than people who always preferred a more solitary lifestyle. It may take a few visits before some people feel at ease with staff and fellow members.  Some new members express a wish to call home to begin with. Staff members often respect this need.  Check to see if the office phone is available and accessible.

Care Managers or Geriatric Care Managers

The term geriatric care manager is definitely more prevalent in the US, but it’s increasingly making its way into the Canadian eldercare vocab. These hands-on health professionals go by many titles: social worker, discharge planner, and case manager, though there are some distinctions between case and care mangers (see next entry). Regardless of title, these caring pros are usually an invaluable part of the care team during and after a stay in the hospital.

A care manager works with older adults and caregivers to identify risks, clarify needs and evaluate options. Often health professionals such as registered nurses, they have extensive knowledge about the cost, quality and availability of services in a community. They can conduct a personalized care-planning assessment to identify existing and potential problems (including safety, nutritional status, and mental state of the elderly individual) and they can also act as liaisons with the local health authorities or insurers to determine eligibility for assistance. Another primary function of a care manger is to talk over potential problems with their clients and their families, helping to look for realistic solutions. In essence, care managers can effectively assume the primary responsibility of the elder on behalf of the family. If you require identification/advocacy with funding sources for your parent’s caregiving needs, your care manager will also be an excellent resource.

Sometimes, the journey through the maze of hospital admission, treatment/rehab and return home is sudden and stressful. Having an assigned support/resource person is truly a blessing and very helpful. Often, however, the family meetings take a while to arrange and ‘decision-time’ is limited. A word to the wise: It’s easy to get lulled or bullied into accepting their first-round advice/recommendations as “must do’s”. You can say ‘ no’, ask for other arrangements, or get a second opinion. Ask lots of questions, double-check everything and advocate on behalf of what you think is best for your parent.  More often than not, a care manager will point you in the right direction but it’s the squeaky wheel that gets the oil.

Case Managers (for older adults)
The role of case managers for older adults, sometimes called a geriatric case manager (see previous entry), definitely overlaps with that of geriatric care managers and the usage of the terms is often quite vague.

Case management is a very diverse profession, but it’s possible to find some case managers who specialize in eldercare. While both case and geriatric care managers can help to manage and coordinate the care of elderly adults, the case manager’s role is generally understood to be somewhat more limited. Though the distinction is fairly fuzzy in Canada, case managers are often reimbursed through public funding or insurance, while you will almost definitely have to pay for a care manager privately.

In the US, case managers generally focus on healthcare issues only, while care managers are responsible for legal, financial, and household issues in addition to healthcare. A case manager can organize assessments to determine eligibility for assistance based on an individual’s needs, coordinate medical services, and arrange for certain other health-related services that a patient might need.

Chiropractors are medical professionals who diagnose and treat disorders of the musculoskeletal and nervous systems without prescribing medications or performing surgery. Utilizing traditional diagnostic testing methods such as x-rays, MRI and lab work, along with specific techniques that involve hands-on manipulation of the articulations of the body, chiropractors work on the belief that one of the main causes of pain and disease is the misalignment of the vertebrae in the spinal column. Through the use of manual detection or palpation, carefully applied pressure, massage and manual manipulation of the vertebrae and joints (called adjustments) chiropractors relieve pressure and irritation on the nerves to restore joint mobility.

Some chiropractors dedicated their practices solely to locating and removing subluxations.  However most chiropractors, in addition to using manual adjustments, also offer other treatment modalities such as physiotherapy, massage, acupuncture and herbal therapy.

Proper oral health is essential to any individual’s overall health, especially in ones later years.  Dentists are the knights of this crusade. These professionals specialize in the lifelong treatment, care and surgeries pertaining to dental and oral health. Most provincial health plans do not cover dental work, even for seniors. Private or long-term care insurance programs usually have coverage for some dental care. Many dental offices are still not senior friendly or accessible. Check first to make sure your dentist’s clinic and equipment can accommodate your parent’s changing needs and mobility limitations. Dental clinics are universities where dental students, supervised by instructors, sometimes offer seniors a cost-effective alternative. There is generally a waiting list for these programs and fees are a percentage of the standard costs for the procedure. Where to find:

Whether your loved one has specific diet requirements linked to an on-going condition, or whether you think that they could just use a little help with their eating habits, you may want to consider seeking the help of a dietician. Registered Dietitians are health professionals and you can access a registered dietitian through a local community health centre, hospital, or branch of the department of health.

You can also arrange for a personal consultation with a dietitian. Dietitians may be able to provide help with planning meals for someone dealing with specific health issues. After assessing the needs involved, dietitians can help with drawing up grocery lists, coming up with practical and healthy recipes, and any other issues relating to diet and lifestyle. Most facilities have on-staff or consulting dieticians who monitor and provide individual recommendations and meal plans for residents. Where to find:

Eldercare accountants
In response to the increase in dual career households and situations where younger adults are away from their parents or unable to provide care, some accountants have begun to provide specialized services and support for the elderly. Expect services to be offered to assure clients that the financial, medical and residential needs of clients or their parents/elderly relatives are met. An eldercare accountant will offer a combination of consulting as well as direct and assurance service that support the elderly living independently or in assisted living facilities while offering the children/spouses or other responsible family members peace of mind that suitable standards are maintained. With access to a network of expertise and services within their geographic areas, accountants with this concentration are qualified to help older adults and their families plan and review care options and costs. Where to find:

Eldercare Lawyer / Attorney
As retirement living and health care decisions are becoming increasingly complex. Families and their seniors often find themselves searching for someone who specializes in areas of the law that are particularly relevant to themselves and their family members. Today, a number of lawyers are devoted to lending expertise and an especially sensitive ear with regards to issues including long-term care planning, insurance, succession planning, public and private pensions, age discrimination, durable powers of attorney, guardianship, and elder abuse. Where to find:

Eye Care – Ophthalmologists, Opticians, & Optometrists
Diminishing eye sight and varying eye conditions affect many people as they get older. If mum’s eyes are not quite what they used to be – consider asking your doctor if she could use a trip to one of these three “O” s!

Optometrists are qualified to diagnose, manage, and treat conditions and diseases of the human eye and visual system. Their practice consists of eye examinations, diagnosis of problems and the prescription of corrective lenses and therapeutic drugs. Dispensing opticians fill the prescription that is written by an optometrist. They design, measure, fit, adapt lenses and help select frames for their clients. Adjustments and repair of frames and lenses are often a necessity for older clients. An ophthalmologist, on the other hand, is a physician who diagnoses and treats eye disease. Ophthalmologists are also trained to administer medication and conduct surgery.

At the first sign of any eye trouble, contact your family doctor who should be able to route you to the appropriate eye specialist, if necessary. Where to find:

Family and General Practitioners
These docs, FP’s and GP’s for short, are the gatekeepers who are primarily responsible for the delivery of comprehensive health care to the general population, regardless of an individual’s culture or age. Given their ability to recognize the impact of family factors in a patient’s medical health and wealth being, FP’s play a pivotal role in eldercare, home care and long-term care.  It is your family doctor who will assist with diagnosis and treatment of conditions based on specialist’s findings and recommendations. Doctors are intimately involved in long-term care and palliative care in the community. They’re your point of entry into ongoing care. Where to find:

Foot-care – Podiatrists
A podiatrist is a physician who deals with the examination, diagnosis, prevention and treatment of diseases and disorders of the foot and its related structures.  Such treatment can be through surgery, medications, mechanics and physical therapy. Many podiatrists perform surgery in their offices, although many also operate in hospitals. They can treat disorders such as walking problems, ankle injuries, broken bones, ingrown toenails and foot infections. Where to find:

Hearing Health – Audiologists / Hearing Aid Specialists
Many people experience hearing loss as they age. Sometimes, hearing loss may simply be due to the aging process, but it can also be caused by exposure to noise, certain medications, infections, illnesses, or hereditary factors.

An audiologist has a masters or doctoral degree in audiology, the science of hearing.  He or she will perform an audiometric evaluation to determine the type and degree of hearing loss and conduct a thorough interview as well as visual inspection of the ear canals and eardrum. The audiologist can suggest medical or surgical alternatives for treating hearing problems. Many audiologists dispense latest technology digital hearing aids, which can be digitally adjusted, or the traditional less expensive analog versions. These professionals also assist in the purchase of related assistive listening devices for the telephone, TV and other listening situations.

Hearing aid specialists have training in the assessment of patients who specifically seek rehabilitation for hearing loss. They are licensed to perform basic hearing tests and can sell and service hearing aids. The assessment and treatment of individuals with hearing loss and the fitting of suitable hearing aids, belong in the scope of practice of an audiologist.

Where to find: Audiologists work in hospitals, schools clinics, rehab facilities and private practice. Your family doctor should be able to put you in touch with an audiologist in your area who could in turn connect you with a hearing aid specialist. Also consider contacting the Canadian Association of Speech-Language Pathologists and Audiologists.

Home Health Care Retailers
Home health care retailers are also referred to as dealers, medical supply stores, or pharmacy home health care departments. These centres should all have qualified professionals on staff to assess, recommend, and provide a range of products and equipment from assistive devices, to respiratory care products and mobility equipment.

While community health professionals and/or physicians can authorize funding support for a significant number of products, especially those requiring complex prescriptions, you should expect to pay for some equipment (especially if you want more than just the basics). However, if you qualify, funding may be available from many employee health care or long-term care insurance policies after your purchase – simply process a claim for a refund.

Look for partial coverage for basics under most provincial health programs for products like walkers and wheelchairs when prescribed by an authorized health professional. For instance the Assistive Devices Program in Ontario provides coverage for qualified individuals (Note: qualifying guidelines vary, may be quite rigorous, and may involve significant waiting time for approvals). See our special chapter for information on what Veterans Affairs might also cover some of the costs.

Rentals and refurbished equipment also offer ways to accommodate short term needs and provide significant savings.

Hospice Care
Hospice is a concept of care rather than a specific place. Choice is at the centre of this

approach which involves special, supportive services for the terminally ill and their families. These services include pain and symptom management, social services and emotional and spiritual support. Hospice palliative care is usually provided in the patient’s home or the home of a loved one where a patient can be surrounded by their treasured possessions, their family and their friends so that they may live out their lives in the comfort of familiar daily routines.  Hospice services may also be provided in long-term care centres or in patient residential settings.

A patient and family may turn to hospice care when the goals of the patient care have switched to comforting and encouraging as much independence and control as possible.

The hospice objective is to preserve the life remaining for the patient and the entire family. Where to find:

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