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Working With Health Care Providers

Looking after the health and wellbeing of a senior or other person in need of assistance can sometimes be a team effort. We're always happy to collaborate with healthcare providers and other caregivers to ensure the best result for our clients. If your parent is in a nursing home or assisted living facility, hospice or hospital, a Del Lago Home Care caregiver can visit them on site, providing emotional as well as physical care, wherever they are.


Hospital Discharge Planning

Discharge planning is the process your family member goes through to prepare them for leaving the hospital. The process may be long or short, depending on why they are in the hospital and how their needs may have changed as a result of their hospitalization. Hospitals have staff people who can help your family make plans-they may be called Discharge Planners, Case Managers or Social Workers depending on the hospital.


What should I think about before my family member leaves the hospital?

Think about what they will need at home and whether anyone at home can take care of their needs. They may need help with any or all of the following:

  • Activities: Will they have to change their daily activities when they get home?
  • Steps: Are there stairs going up to the home or to get to the bathroom?
  • Medication: Do they have the necessary information about medications? Will they be able to take them without reminders and assistance?
  • Errands: How will they pick up prescription drugs and groceries?
  • Transportation: How will they get home from the hospital? How will they get to their follow up doctors' appointments and other activities once home?
  • Food: Can they prepare meals? Do they have food in the house? Will their diet change?
  • Personal Care: Will they need help showering, in the bathroom, or eating?
  • Household Chores: Will they need help with cooking, cleaning or laundry?
  • Equipment: Will they need a commode or shower chair?

A Hospital Discharge Planner, Case Manager, or Social Worker is available to help you plan for care when you are leaving the hospital. This person can help you arrange for services. Synergy HomeCare can start services at the time of discharge in the hospital and be on hand through the discharge and transportation to “tuck in” safely back home. Services can continue and ensure the discharge plan is carefully followed all the way to complete recovery.


Skilled Nursing Facilities with Rehab or Subacute Rehab

Sometimes patients, especially seniors, are discharged from the hospital needing temporary skilled nursing care or rehabilitation – perhaps caused by a fall and a broken hip – before returning home or to a residential facility. They will go to a sub acute rehab or Skilled Nursing Facility Rehab. After a one-or-two-month Nursing Home stay, the senior may be able to return home and continue receiving some services such as physical therapy along with home care services. Del Lago Home Care will help with that transition from rehab to home and provide the home care services needed to keep your family member on the road to a safe recovery.


Home Health Care

Home health care – or “skilled nursing” – is not intended to provide the same services as non-medical home care. As a result, Del Lago Home Care works with home health agencies and their patients to complement each other's services providing comprehensive care and continuing where home health leaves off.

Home health care is skilled nursing care and certain other health care services that you get in your home for the treatment of an illness or injury. People often receive home health care services following a hospitalization.

All Medicare beneficiaries can receive home health care benefits. However, to get Medicare home health care:

  • Your doctor must decide that you need medical care in your home, and make a plan for your care at home.
  • You must need at least one of the following:
    • Intermittent (and not full time) skilled nursing care
    • Physical therapy
    • Speech language pathology services
  • You must be homebound. This means that you are normally unable to leave home. Being homebound means that leaving home is a major effort. When you leave home, it must be infrequent, for a short time, or to get medical care.
  • The home health agency caring for you must be approved by the Medicare program.

If you meet all four of the above conditions for home health care, Medicare will cover:

  • Skilled nursing care on a part time or intermittent basis.
  • Home health aide services on a part- time or intermittent basis and only when you are also getting skilled care therapy.
  • Physical therapy, speech language pathology services, and occupational therapy for as long as your doctor says you need it.
  • Medical social services to help you with social and emotional concerns you have related to your illness.
  • Certain medical supplies, but not drugs or prescriptions.
  • Certain pieces of medical equipment, such as a wheelchair or walker.

Medicare will cover any of these kinds of therapy for as long as you are eligible and your doctor continues to say you need them.


Continuing Care Retirement Communities

Del Lago Home Care works in Continuing Care Retirement Communities (CCRCs) throughout the United States. CCRCs provide independent living, housing-with-services, and nursing home care in one location, enabling seniors to remain in a familiar setting as they grow older. Many seniors enter a continuing care community while they are healthy and active, knowing they will be able to stay in the same community and receive nursing home care should this become necessary. If a senior requires nursing home care for a while and then becomes well enough to again live independently, they can move back to an independent living arrangement without leaving the continuing care community.

This need for flexible services is a perfect match for the “No Contracts, Just Care” philosophy of Del Lago Home Care. It is a priority for our caregiver relationships to stay strong and consistent through changing needs.


Healthcare Professionals and Recognizing When Parents Need Help

It is not always easy to recognize when aging parents need help. The AARP suggests that you and your family discuss the well-being and safety of aging family members. Be sure to include your parents' doctor(s) in these discussions.

If you feel that additional assessments are necessary, some hospitals, clinics, agencies on aging, and certain health professionals known as geriatric care managers can provide a “geriatric assessment” – a thorough evaluation of a person's physical, mental, environmental, and in some cases, financial and legal needs. This assessment can also identify risks to the aging person's wellbeing, providing recommendations to reduce those risks, and suggestions on where to go to for support. More important, it can help the health professional(s) determine your parents' ability to remain independent.

Del Lago Home Care is privileged to work with the health care professionals that provide services and support to families like yours.

The AARP suggests these questions for discussion with health care professionals and your family to help you identify potential problems and allow you to act in those areas of your parents' lives that need attention:

  • Physical Health Do your parents have one or more chronic diseases, such as arthritis, diabetes, emphysema, or high blood pressure? Have they been diagnosed with other diseases, such as cancer, heart disease, or stroke? Do they have problems with their bowels, bladder, vision or hearing? Do they have difficulty walking? Who are their health care providers and hospitals?
  • Mental Health Have one or both parents been diagnosed with depression, anxiety, psychosis, Alzheimer's Disease, or another form of dementia? Do they become forgetful, confused, disoriented, or seem isolated from friends and family? Do they experience mood swings, sadness, or loneliness?
  • Medications What prescription and over-the-counter medications are your parents currently taking? What is the dosage for each drug? How often should these drugs be taken? What are the side effects? Are they taking medications as directed? Which pharmacy do they use?
  • Daily Living Skills Can your parents feed themselves, bathe, dress, use a toilet, climb stairs, or use the phone with little or no assistance? Do they know how to use the telephone to call friends or family and 911 in the event of an emergency? Are they able to shop, prepare meals, do laundry, clean the home, and do yard work?
  • Hygiene and Appearance Do your parents bathe and brush their teeth regularly? Can they attend to grooming needs such as washing and combing hair and clipping nails? Do they wear clean clothes?
  • Safety Is your parents' neighborhood safe? Is the home or apartment equipped with working smoke detectors, and can they hear them adequately? Are there adequate locks on their doors and windows? Can they avoid telephone and door-to-door fraud? Can they safely drive or get around on foot or by public transportation without getting lost?
  • Social Support Do your parents visit with family and friends or get out of the house for other social reasons (senior center activities, place of worship)? Do they have a list of family and friends' names, addresses, and phone numbers near the telephone in case of an emergency?
  • Finances Does your parents' current income adequately cover monthly living expenses? Do they have insurance? Will the income or insurance cover additional expenses in the event short or long-term care is needed? Do they pay bills on time? Are they able to make informed financial decisions?
  • Legal Issues Do your parents have updated legal documents such as trusts, living wills, and/or durable power of attorney? Are they able to make informed legal decisions?
  • Interests Are your parents involved in one or more hobbies? Do they read books, watch favorite TV shows, exercise, or play musical instruments?

Independent living facilities are for people who want to live independently but do not want to maintain a home. We often work with independent living facilities to provide a full range of home care services to residents when they need a little extra support.

Assisted living facilities are an eldercare alternative for people for whom independent living is no longer appropriate but who don't need the 24-hour medical care provided by a nursing home. Assisted living is a philosophy of care promoting independence and dignity. These facilities are regulated and licensed at the state level and are sometimes called Residential Care Homes, Assisted Care Living Facilities, and Personal Care Homes.

A growing number of assisted living facilities accept residents with higher care needs, allowing them to arrange for their own personal care services. Synergy HomeCare often provides those extra services, which can allow your aging parent or family member to stay safely in the assisted living community they have come to call home.

If your senior family member is a resident at an assisted living facility, you may want to consider asking a Del Lago Home Care caregiver to provide:

  • Supplemental services that the assisted living facility is not equipped for (for example personal, accompanied transportation to doctor's appointments or to family and friends, off site, extended companionship, additional personal care etc).
  • Care while your senior parent is still in their own home but is on the waiting list of an assisted living facility.
  • Temporary services so your family member can remain home at the facility while recovering from a setback (illness, hospitalization, etc).
  • Visiting services in a hospital or rehab if your senior parent is waiting to go home to an assisted living facility. This important service offers your senior all of the reassurance that comes from seeing familiar caregivers and continuity of care.


Hospice and End of Life Care

Hospice focuses on caring, not curing, and in most cases care is provided in the person's home. Hospice care is also provided in freestanding hospice centers, hospitals, and nursing homes and other long-term care facilities. Hospice services are available to patients of any age, religion, race, or illness.

Hospice is a philosophy and hospice care is specialized care unlike any other. It calls for a certain kind of caregiver, and a certain kind of sensitive expertise, paying equal attention to both the patient and the family.

Del Lago Home Care is proud to work with all types of hospices; for profit, non-profit, independent and national hospice companies, across the country. When we work with hospice teams, our experienced Del Lago Home Care caregivers make sure we work seamlessly with the hospice team to give exactly the right support for both the patient and your family. Whether we're providing:

  • In-home services that supplement the hospice team
  • Respite support for a short, much needed, break from the daily demands on loving family members
  • Homemaking services to relieve family members or a bereaved spouse
  • Coordinating safe transportation for patients who aren't homebound