Rothkoff Law Group follows a unique elder law firm model called Life Care Planning (find out more at lcplfa.org). This model encouraged its law firms to hire Care Coordinators (usually a social worker or nurse) to help clients navigate the long-term care maze. We often hear, “What does the care coordinator do?”
When we tell folks that our firm has three social on staff, the reaction is either delight or confusion (or sometimes both). Below is an example of a typical client of Rothkoff Law Group (no actual confidential information is being shared).
Mr. and Mrs. Jones have been married since 1952. They have two adult children and still live in their home of 30 years. For the past six years, Mrs. Jones has been the primary caregiver of Mr. Jones who is living with dementia. Mr. Jones does not have any other medical issues other than moderate stage Alzheimer’s. Mrs. Jones, however, has diabetes, hypertension, asthma, two bad knees and is overweight. Their daughter, Monica, comes by to help her parents, but she works full-time and has three school-aged children. The Jones’ son lives out-of-state.
Mrs. Jones, faced with deteriorating health and the exhaustion of being a full-time caregiver for her husband, has begun seeking options for long-term care. Taking this step was difficult for Mrs. Jones, as she realized that their monthly income of $3,400 would not pay for very much and that their assets, the value of their home and $98,000 in cash, would be depleted very quickly.
Mrs. Jones and her children met with our office. At the meeting Mrs. Jones and her children learned about the VA Aid and Attendance Benefit that can be added to their monthly income of $3,400, bringing them up to around $5,400 a month. They also learned the importance of getting Mr. and Mrs. Jones’ powers of attorney, advance directives and wills updated. After they decided to retain us, the Rothkoff team got busy. Our VA specialist, Joanne Solometo, started working on the VA application. An appointment was also established to meet Mr. and Mrs. Jones in their home.
In the home, Janie DeLeon Male, our Director of Care Coordination, set about to do the following list of items for the Jones family:
- Assess Mr. and Mrs. Jones in their home for safety issues (recommend a shower chair, pull-down shower head, removing items off the floor, etc) ;
- Screen both Mr. And Mrs. Jones for depression
- Assist in getting the powers of attorney, advance directive, the wills, and VA application signed at their home so that Mr. Jones would not have to travel to an unfamiliar place;
- Educate Mrs. Jones on UTIs, medication management, caregiver stress, hospice and long-term care options;
- Offer referrals to various doctors such as geriatricians, geriatric psychiatrists, podiatrists and eye doctors as appropriate
- Explore the options for getting some help in the home to assist with caring for Mr. Jones;
- Explore the idea of assisted living care for Mr. Jones, including using day care or respite care in an assisted living community;
- Encourage Mrs. Jones to seek support through support groups or individual therapy from a Medicare provider.
After accomplishing the above issues, all recommendations and referrals were shared with both Mrs. Jones and her children. The family set about touring assisted living communities and interviewing home care companies. Two months later, however, Mrs. Jones suffered a major stroke. The daughter asked a neighbor to watch dad and went to the ER with mom. Mrs. Jones was admitted to the hospital for an undetermined length of time. The daughter, Monica, called us the next day and Janie responded with the following actions:
- Called one of the assisted living communities the family had toured to discuss immediate placement in a memory care unit for respite care for Mr. Jones;
- Connected the daughter and the community relations person after preparing the daughter for the admission process;
- Educated the daughter on several topics concerning her mother, including confusion/disorientation during the hospital stay and the process of choosing and entering a rehabilitation facility; Provided on-going phone and email support to the daughter throughout this period;
- Visited dad at the assisted living, consulting with their nurse about Mr. Jones’ adjustment to the community;
- Attended the father’s care plan meeting at the rehab facility;
Mrs. Jones stayed in rehab for 52 days. At that time a decision had to be made as to whether Mrs. Jones could go home, move to assisted living or stay in the nursing home for long-term care. Monica called Dawn to discuss the situation.
Janie’s role then:
- Janie went with Monica to the next care plan meeting to gather the facts on Mrs. Jones. It was determined that due to immobility issues and other medical conditions Mrs. Jones would need to stay in the nursing facility for long-term care. The nursing home agreed to keep Mrs. Jones.
- Janie then educated and discussed with the daughter how to be an advocate for her mother and father including attending care plan meetings, following the chain of command in each facility, getting to know the caregivers, etc.
- Janie reminded the daughter to our office if she has any questions or if she feels that after advocating for her parents she needs some additional support from the care coordinator.
Meanwhile, our office continued to file for Veterans Benefits for Mr. Jones and began a nursing home Medicaid application for Mrs. Jones, involving our Medicaid specialist, Alicia Kagan. We also reviewed Mr. And Mrs. Jones health insurance through our health insurance specialist, David Goldwasser.
In the end, this family, like so many clients, started off on one track to meet their father’s needs and ended up needing a different plan to help both mom and dad. We were able to provide them with guidance and support throughout the changes, employing all members of our team. The care coordinator played a significant role in helping this family navigate the long-term care world, sticking with them through each transition.