1st Phase -- Comprehensive Geriatric Assessment with Recommendation of Solution Choices
A geriatric care manager (GCM), who is a licensed health care professional, performs a Comprehensive Geriatric Assessment (CGA) to correctly assess problems, challenges, risks & issues that pertain to a patient’s overall health status as well as their safety & welfare. The CGA visit(s) encompasses all facets related to a patient’s total health picture, lifestyle & physical and psychosocial well-being. This definitely includes assessment of medication regimen, compliance level, & need for reconciliation & medication management, as well as a home safety evaluation for any health hazards or safety risks. When the CGA is completed and all areas of the patient’s life has been assessed and all challenges/risks have been identified, the GCM is then able to focus on specific solutions that will adequately address those challenges, risks, & issues present.
2nd Phase -- Development of a Customized Care Plan & Execution of the Plan
In this phase, the GCM prepares and drafts a personalized & unique plan of care to address the problems, challenges, risks and needs identified from the assessment segment and provides a care map so-to-speak, of how the patient can best be taken care of to meet specific goals identified. This map or plan is created in conjunction with the patient and/or family. The customized care plan provides the written framework for addressing and organizing the patient’s personal health & safety priorities. This care plan gives the GCM, family, & patient, the vision and direction for the specific care options to take place. This is what fosters the best possible solutions & outcomes. The customized care plan is activated & executed by the GCM who provides & supervises for an assortment of various care management solutions and interventions for the patient.
3rd Phase -- Follow Up Assessments & Communication Reports
This phase is actually an ongoing phase from this point forward. Once the patient has had the benefit of several solutions put into place and the original needs, deficits, and concerns are being addressed & are resolving, the GCM will continue working with the patient in a long term strategy to continually assess & reassess the patient’s home situation and health picture. This long term management & oversight allows for regularly scheduled monitoring. The GCM makes follow up visits to service, maintain, & reassess the patient’s specific situation. These follow up visits are important to check on the plan of care and confirm that the patient is on track for reaching his/her goals. The details and report of these follow up visits are then communicated back to the family members, primary care physician and other healthcare professionals. Written and verbal communication guarantees that all key members are kept informed on the patient’s current status & progress as well as the reporting of any emergence of new concerns.