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Hospital to Home to Assisted Living: Managing Eldercare

Care managers play vital role during transitions

Care options can be numerous, confusing, and overwhelming. The average person probably does not know where to begin when it comes to making decisions for care following a parent’s crisis-driven hospital stay. Adult children often are charged with choosing a care facility or alternative situation for their parents with nothing to go on beyond a cryptic list from the hospital.

“Before my mother was in the hospital I didn’t know the difference between ‘acute’ rehab and ‘sub acute’ rehab,” recalls David Zoll, Parentgiving co-founder and son of Shirley Zoll. The hospital may give you no more than two days’ notice to find a facility for your parent, “and while the discharge planner and hospital social workers may be nice people, they don’t have the necessary time to go through the depths of the care options available, figuring out how to choose one, and communicating between the hospital and the rehab facility.” That’s where the care manager comes in.

“The care manager can help you sort out the jigsaw puzzle and slow down the discharge process with the hospital so you have time to figure out the best options for your parent,” David says. “Plus, dealing with your elderly parent and other family members often becomes very emotional. The care manager is an independent voice of reason.”

Coordinating all aspects of care

“When Shirley was in the hospital, I helped David figure out where she should go for rehabilitation,” says Nancy Bortinger, LCSW, and licensed care manager. “I looked into different facilities to find out information about state inspections and the overall environment, and I accompanied him on site visits.”

Once Shirley was placed into rehab, the next step was figuring out her best options for post-rehab. Shirley was accustomed to living independently in an apartment, but her health situation was unstable and Bortinger questioned her ability to continue living on her own without help. “She wanted to think nothing had changed and she would be OK living as she had before,” recalls Bortinger. “But the reality was that, due to a blood disorder, one week she was strong and another week she was weak.”

"The care manager can help you sort out the jigsaw puzzle and slow down the discharge process with the hospital so you have time to figure out the best options for your parent. Plus, [when] dealing with the elder and family members, the care manager is an independent voice of reason." - David Zoll, Co-Founder, Parentgiving Inc.

Geography also came into play during the decision-making process. Shirley had been living in Massachusetts, but David resides in New Jersey. Shirley’s hospital stay and rehab took place in New Jersey, but she was determined to return to her home state. Bortinger continued to help David and Shirley review living options in New Jersey, including independent living in an apartment and assisted living. Eventually, though, Shirley returned to her apartment in Massachusetts.

A team approach to ongoing care management?

Her health still a concern, Shirley had good days and challenging days once at home in Massachusetts. To ease his concerns about Shirley’s health and his geographic distance, David found a care management team in Massachusetts to assist Shirley and the family as necessary. Shirley’s care management consisted of two professionals: a nurse and a social worker. “It was a great combination because we worked more with the nurse when we had hospital and other medical issues and when medical conditions were stabilized, the social worker helped with housing, family dynamics, and other everyday concerns,” David explains.


An abrupt change in care needs

After 18 months of living at home, Shirley contracted a mysterious, debilitating illness that came out of nowhere. Once she regained her health, she went to subacute care for rehabilitation, and agreed to a brief respite at an assisted living facility for an additional period of recovery. As it turned out, she enjoyed the sociability, support and independence the facility provided. She had her own apartment there, but also had access to activities, social interaction and amenities that were not available at home. At that point, she and David, with the input of her care management team, agreed that the best environment for her was an assisted living care facility.


“Especially if the adult children live out of town, it is critical to have someone like a local care manager to oversee the home care aides, accompany the elder on doctors’ visits, and constantly assess their physical and emotional state,” says David. In addition, the care manager can assess the elder’s living space and make recommendations for a safer home environment.

The amount of time care managers spend with patients and families varies. In Shirley’s case, the home care managers spent about five hours per week, including care visits and trips to the doctors. “They might have put in more hours when she was in the hospital and it receded when there was medical stability,” David notes. “But they were available to us indefinitely as a back drop of help. Since I couldn’t be there all of the time, it was a tremendous relief to know I had a care management team we could count on.”