Author Archives: Dianne Savastano

Hiring and Managing Professional Caregivers

Last month, I wrote about hiring private caregivers to care for a loved one in your home. I explained that one of the first questions that needs answering is whether the help is needed to assist rehabilitation — in which the individual being cared for will regain functional abilities and possibly get better — or if caregivers are being hired to care for someone slowly declining or at the end of their life.

Whatever the specifics, when hiring someone it is your responsibility (and in your best interest!) to do all you can to provide support, training, and guidance, to help that person succeed. An investment of time, energy, and commitment up front increases the likelihood of a positive experience and a successful relationship.

Further, and as a result of our years working with clients, we have developed “tools” that can be customized to meet individual circumstances. I share them in the sections below and encourage you to amend them as needed.

Planning and Introduction

You’ll want to set aside time to develop an orientation plan and schedule. Think about how you can relay your “insider knowledge” regarding your loved one — their health status, routines, likes and dislikes, etc. — so that you provide as much data as you can about the person being cared for.

But first, and before the actual caregiving begins, be sure to create an opportunity for the caregiver and your loved one to meet and get to know each other. This is an important first step in what will become a deeply personal relationship. Sometimes, in the haste of making numerous arrangements (especially if someone is being discharged from a facility), this is overlooked and can contribute to a poor outcome.

Orientation / Training / Setting Expectations

The first tool we create is a Daily Schedule / Routine. This may require revision over time, but initially, it provides a roadmap for the caregiver to “fill-in” as needed while preserving the functional abilities your loved one is capable of executing independently. The goal is for the caregiver to ease into a routine that allows your loved one to graciously accept assistance that they may not initially perceive as needed.

When this phase is not well executed, caregivers often feel that they are unable to anticipate the needs of the person for whom they are caring, while family members feel that the caregiver took too much or too little initiative. This can lead to resistance on the part of the person being cared for, leading to the often-heard comment, “I don’t want a stranger in my home.”

This important first step helps to avoid disruption, frustration, and a revolving door of caregivers being hired and fired in search of “the right one.” As in any hiring relationship, an investment at the beginning pays off in the end.

Emergency Procedures

Unfortunately, emergencies do occur. Establishing and documenting an Emergency Procedure reassures both the caregiver and your extended family by clearly specifying responsibilities.

Additionally, the Emergency Procedure tool becomes the face sheet of the ‘Grab-n-Go Kit’ discussed in a previous newsletter.

Responsibilities / Priorities / Home Health Aide

This tool mirrors the Daily Schedule / Routine but provides much more detail to the caregiver about their individual responsibilities in support of that routine.

Because individuals being cared for at home may require a caregiver to perform functions that began in institutional settings, more detailed training may be necessary for the caregiver, whether by a professional or family member. Examples include caring for a Foley catheter or periodically testing blood sugar.

Think ahead and capitalize on the opportunity for hospital, skilled nursing facility, or visiting nurse agency staff to provide such training.

Household Responsibilities for Home Health Aide

A common question from families is whether it’s alright to ask a caregiver to assist with household responsibilities such as cooking and laundry. The answer is yes; the physical environment in which your loved one resides must be kept neat and clean, thus ensuring their safety and comfort.

This tool provides an example of how household responsibilities were compiled and clearly specified within a simple document.

Responsibilities When in Rehabilitation Mode

When caring for someone who has recently returned home from a hospital or skilled nursing facility following an acute illness or injury, real-time data gathering is important — it contributes to the decision making that will eventually lead to greater autonomy on the part of the person being cared for.

For example, when one of our clients who was still quite ill returned home from the hospital following surgery, this toolallowed the caregiver to monitor and document items that were critical in the beginning but that became less so as time went on. Items included fluid intake, urine output, blood pressure, weight, number of times per day getting out of bed, and whether or not the outlined list of daily exercises were performed as recommended. Additional notes described observations about eating patterns, pain management, and overall mood.

The caregivers were encouraged to offer suggestions for each other and for family, thereby facilitating the sharing of insider knowledge among members of the support team. This communication step is important and should not be overlooked.

Interests and Social Activities

This tool helps outline the specific activities an individual enjoys — it is invaluable information for a caregiver to have.

Knowing what motivates a person or what can make them smile helps to facilitate conversation and can provide an activity to look forward to accomplishing in a given day.

Final Thoughts

Developing successful caregiver relationships between loved ones, caregivers, and extended family takes planning, training, and constant nurturing.

By sharing your “insider knowledge” about a loved one with caregivers, and by caregivers, in turn, gathering real-time information to share with you and other team members, you help to ensure a positive experience for all concerned.

Recommended Reading and Resources: Effects of Ageism

Exploring the Health Effects of Ageism

Ageism is detrimental in so many ways.


This form of memory loss is common — but most Americans do not know about it

A good summary of steps one should take if you notice cognitive changes in a loved one.


Medicare Advantage plans send ‘Papa pals’ to seniors’ homes for companionship

An interesting piece about some Medicare Advantage Plans that are sending “pals” into the homes of some of its members. I have mixed feelings about the program — it feels a bit too invasive to me, although I do see the value. Please let me know your thoughts!

My Mom Has Become a Statistic

According to the Centers for Disease Control and Prevention (CDC), an older adult falls every second of every day in the US.Last month, my mom joined the ranks, suffering multiple fractures from a fall in my home. As I continued my role as her primary Care Partner, I also became her primary Caregiver.

Mom is making tremendous progress and, fortunately, all the professionals in her life believe she will walk independently again. For that I am grateful. However, I now understand, firsthand, the tremendous toll that a fall like this can take on a family. Today, I share some ideas regarding things you can do if you find yourself in similar circumstances.

How Medicare/Insurance works

For Medicare/insurance to pay for an individual to receive care in a skilled nursing facility (SNF: inpatient care utilized after a hospital stay, following an accident, severe illness, or surgery), certain conditions must be met. The goal is to help the person regain their ability to do “activities of daily living” such as bathing, dressing, cooking, personal hygiene, walking, and getting into/out of a bed or chair.

The determination of whether an individual continuously meets the criteria for payment in a SNF is scrutinized by insurance-based personnel. They rely on documentation provided by onsite physical and occupational therapists, who outline the objective and quantifiable physical goals an individual must work towards and meet. Upon admission to a SNF, and based on an algorithm, a discharge date is projected and immediately communicated to the family.

In this situation, our clients frequently experience two powerful emotions: fear, followed by anger. I felt both of these!

In my case, the fear came from wondering how I could possibly care for my mother at home by the date that was communicated. The anger came from being forced to worry about mom’s impending discharge at the same time as I was worried about her immediate injuries and what lies ahead for her and for my dad.

Just when I needed reassurance that things would be okay, it felt like I was being threatened that care would be taken away. I know “threatened” is a harsh word, but I felt it.

First, I was told that she did not qualify for hospitalization beyond the emergency department visit and that she had to leave within 24 hours. Then I was told the SNF stay would be short, because she was non-weight bearing. She would therefore fail to qualify for continued aggressive physical and occupational therapy until she could put weight on her foot and arm (that was 12 weeks away).

Once home and receiving home-based care, the projected discharge date from that level of care to outpatient physical therapy (to which she needs to be transported regularly) was quickly communicated.

Overall, and despite my vast knowledge and experience managing all of this with our clients as well as my deep understanding of how Medicare/insurance functions, it still felt awful. It felt like the healthcare/insurance systems were not supporting us as a family the way we needed to be supported.

Take Charge of the Situation

When someone has a traumatic fall that results in a hospitalization, a stay at a SNF, and an eventual transition home, it’s critical that someone in the family take charge. There is so much to quickly manage and learn.

I understood how important it was for mom’s first transition to be to a SNF that was of high quality, so finding that became my first and highest priority. That decision set the tone for her recovery, and I am grateful to have found a SNF team that communicated with transparency and that worked in partnership with us to achieve the outlined goals.

But make no mistake… this took me away from everything else in my life (to those clients for whom I have been less responsive, thank you for understanding). Compromises had to be made to attend to the immediate matter and I had to be the one to step up.

If you have siblings or others with whom you can share responsibilities, make it known immediately that you need help and assign tasks. I am so grateful that in our situation, my dad, Anthony, and my husband, Bob, were on mom’s team. Working together made it all just a little bit easier.

Challenge the Jargon

When you are dealing with health care professionals, whether in a hospital, a SNF, or with therapists providing care in the home, the professional language they use can sound very foreign.

“Max assist,” “contact guard,” “instrumental activities of daily living,” “core muscles, “motor planning,” “proprioception,” etc., etc. This terminology is used to describe an individual’s abilities, the goals they are working toward, and how progress is being measured.

But what do the words actually mean? To a lay person, such language is ineffective at communicating what your loved one’s needs will be when they return home to you.

So, when meeting with these professionals, ask for explanations. Here is some of what we asked…

  • What are the measurable and quantifiable goals mom is working towards?
  • What can she do alone and what does she need help with?
  • What kind of help does she need to get out of bed? Can I do it alone or will she need the assistance of two people?
  • What equipment can be used to help her?
  • Can I attend your therapy sessions with mom so I can observe and learn?
  • Can you provide training to me and my dad?
  • Can we practice what needs to be done so you can provide tips and help us develop solutions to problems we may encounter when she is in our home environment?
  • Can you come to our home to do a home-based assessment so you can see what the layout is and offer suggestions?
  • How do I get over my fear of bringing her home?

For the first two weeks mom was home, dad and I worked together to perform every change in position while she was in bed and to manage every transition into and out of her wheelchair. With a broken shoulder and broken foot, mom could do very little for herself and yet, because the therapists stated that she could transfer with the assistance of just one person, she was ineligible to stay in the SNF for any longer.

What I realized after those two weeks is that I could have done some things alone, as the therapists did. But I was dealing with incredible fear that I would drop her, causing greater injury. If you find yourself in this situation, make the best use of the experience of every professional you encounter along the way. Ask them to not only teach you but to practice with you.

Everything gradually improved, but in the meantime, there was a lot of sleep lost and quite a few tears.

Know Your Rights; Push Back as Needed

If your loved one is receiving care from a hospital, SNF, Hospice, or from a Home Health Agency and you are told that Medicare/insurance will no longer pay for care, you have the right to an expedited appeal. There are separate processes, depending on the type of facility and the type of insurance. There are also different levels of appeal if you are unsuccessful with the expedited one.

Overall, determinations will be made based on the quality of documentation provided by the medical personnel, along with other factors. So, educate yourself beforehand about this topic, in case you need to take action.

In our case, and without a formal appeal process, I was successful at negotiating four additional days in the SNF as well as an insurance-covered ambulance ride to see a specialist about a complication mom was experiencing. The outcome of that visit had a life-changing result, allowing mom to resume normal bodily functions.

I believe that the open communication and the relationships I developed with everyone in the SNF, the insurance case manager, and the specialist’s team of professionals along the way, helped to make it all happen. But that is not always enough, so be sure to know your rights.

Final Thoughts

A phrase that has become common in our household as we continue to progress through this experience is, “It’s all about the pee, the poop, and the pants!” Managing this intimate function of getting pants up and down still causes us to break out in laughter, because invariably, I forget one of the multiple steps in the process.

Being able to laugh loudly and often has helped us so much and is a reflection of the precious relationship I enjoy with my parents. I hope you never have this experience, but if you do, I hope you can find laughter, too!

Recommended Reading and Resources: Relaxation

The Relaxation Response

I was saddened to learn that Dr. Henry Benson, author of The Relaxation Response, had passed. Published in 1975, while I was in college, this book has informed me every day since.

I also had the good fortune to attend a 10-week course on meditation at The Benson-Henry Institute for Mind Body Medicine. That, too, was life changing. Following the experience, I adopted a meditation practice — only about 15 minutes daily and so worth the time.


The Seven Habits That Lead to Happiness in Old Age

“Your well-being is like a retirement account: The sooner you invest, the greater your returns will be.”

I just loved reading this. How many of these habits do you have in your life?

I shared this article with my dad, and he said: “I knew all this; this is what I’ve done for my 87 years. Except for #3. Maintaining a normal body weight has never been my strong suit. Six out of seven isn’t bad!”

Advance Preparation Helps Avoid a Crisis

Last month, my mom experienced a fall in our home that resulted in left-sided fractures of her shoulder and foot. As I ran to assist her, I tried to calmly assess the situation; I determined that she needed emergency care. That’s when I went from daughter to Care Partnermode.

Fortunately, she is on the mend and, all things considered, it was a positive experience. But it didn’t happen by accident (no pun intended!). Much of our success can be attributed to our preparation before the event and to steps taken once it occurred. I share these with you now, in the hope that you will also be prepared for such an incident.

Effective and Efficient Communication

I called 911 and gave a description of what happened to the phone dispatcher and to emergency responders who quickly arrived. I shared critical information about my mom, her baseline of health, and her functional abilities, all of which allowed them to do a thorough assessment and to begin treating her immediately.

For example, a key comment was, “Mom wears hearing aids and she does not have them in. Please speak directly to her and watch her face to promote communication.” That helped tremendously.

Grab-n-Go Kit

Fortunately, I had a copy of mom’s “Grab-n-Go Kit” — a preassembled packet of information about an individual that you can access at a moment’s notice. I quickly retrieved several key documents from it. The emergency team wanted to know about mom’s medical conditions, her medications, and allergies. The man doing the intake saw what I had in my hands and said, “Wow, we never get this. This is incredibly helpful!”

Some of the contents of a Grab-n-Go Kit include:

  • “Face Sheet.” Demographic information and things one should know. For example, mom’s hearing impairment was noted in bold letters at the top of the page.
  • Medication list. Both prescribed and over the counter, including dosage and how often taken
  • Medical Conditions, Past Surgeries, Past Hospitalizations List

Some clients resist my suggestion for a paper kit and insist that all their information is in their electronic record or available on their Patient Portals. That may be true, but not all medical record systems are shared and when an emergency occurs, the speed with which information can be extracted and communicated is critical.

Emergency Room

In the current COVID-19 environment, accompanying anyone to the emergency room is often prohibited. As you might imagine, I went anyway!

As mom was taken in through the rear entrance, I introduced myself to the personnel at the front desk. Although they suggested I leave, I stated that I had mom’s identification, insurance information, and quite a bit of medical information that might be of value to the physicians examining her. I was then asked to wait. Soon, a nurse came out asking many questions that were critical to mom’s care. Before I knew it, I was asked to join the assessment team.

I’m certainly not suggesting that you should ignore the rules. However, I am saying that when you have valuable information about your loved one, you must find a way to share it expeditiously.

Insurance Company

After mom was thoroughly assessed by multiple medical personnel, a treatment plan was developed that included splinting her left arm and casting her left foot with the recommendation that she be non-weight bearing on her upper left AND lower left extremity for 12 weeks! That meant working with the hospital-based case manager on a transition to a Skilled Nursing Facility.

When I got home, I immediately did the following…

… I went onto mom’s insurance portal to review the benefits for skilled nursing care

… I began to assess the facilities in our area that were considered in-network under her Florida-based Medicare Advantage Plan

… I called the insurer early the next morning to verify my understanding

By the time the Case Manager called me, I had five facilities listed that had high quality care ratings. When the facility that was my first choice said “no” — based on their belief that mom was not covered under her plan — I called and facilitated a three-way conversation between myself, the business manager at the facility, and the insurer, to clarify that mom did indeed have coverage. She was transferred that afternoon, 24 hours after the incident occurred.

The lesson here is to be familiar with your insurance coverage and that of vulnerable loved ones in your life. Do your own homework, both in advance and in the moment, and verify your understanding. When someone tells you something different than what you know to be true, politely and assertively Challenge the Process.

Documentation

I’m someone who documents everything — in these circumstances, I suggest you do the same. I quickly organized a notepad and within 24 hours, I made entries from interactions I had with the following professionals:

  • Physician and nurses at the hospital
  • Hospital Case Manager
  • Insurance company customer service personnel
  • Admissions and financial personnel at the Skilled Nursing Facility
  • Medical, nursing, social work, and rehabilitation staff at the Skilled Nursing Facility
  • Insurance Case Manager

Within those first 24 hours, so much happened that I needed to remember, much of which was critical in setting the course for mom’s plan of care. Having the names and phone numbers of everyone with whom I interacted has helped me tremendously over the past five weeks. I could not have done it without my notebook!

It’s All About the Relationships

In working with all the professionals along the way, I tried hard to create positive and collaborative relationships.Each individual had their role and their perspective, all of which helped to inform me.

Not everything went smoothly. But when I needed to challenge the process, and when I knew it was the right thing to do on mom’s behalf, the positive relationships I built helped us to get the best care possible.

Final Thoughts

Many times over the past several months I have mentioned that our role at Health assist is to be a “futurist” — anticipating how illness and aging can impact our clients’ functional abilities and capacity to care for themselves.

With my futurist hat on, I’m as prepared as I can be to care for my mom and dad. And yet, this incident continues to test me and my parents. When mom mentions, as she does often, how bad she feels about making so much work for me, I say, “That’s what families do for each other. Isn’t that what you always taught me?” I would not have it any other way.