Behind the Scenes: Managing Residential Transitions - Part 3

In this three-part series, we are following Diane Peabody, R.N., an elder care coordinator at Applegate & Dillman Elder Law, a Life Care Planning Law Firm in Carmel, Indiana, as she works with a family to relocate Jolene, the family matriarch who had been living in Florida, to a nursing home near her sons in the Indianapolis area.

When our story ended last month, Jolene was being airlifted from Florida to Indianapolis. She arrived at her new home, a skilled nursing facility, and Diane met up with Jolene to complete the initial assessment. “I don't do an actual physical assessment like the facility doctor or nurse does,” Diane notes. “But, as Elder Care Coordinators, we consider the client’s medical and nursing diagnoses, ADL’s (activities of daily living), cognition, and mental capacity, which impact the client’s ability to sign documents. We also explore other potential concerns, such as nutrition, sleep issues, support systems for client/family, and complete a summary with recommendations related to Life Care Planning.

Not long after Diane completed the initial assessment, Jolene took a fall. When the sons expressed concern about the level of care, Diane stepped in to assist in exploring any care concerns. She talked with the Director of Social Services and the nursing staff at the facility. “I coordinated communications between Jolene, her sons, and the facility to make sure that fall prevention measures were taken and that all the care-related concerns were addressed,” Diane remembers. “Jolene’s fall sparked several impromptu care conferences via phone and email, so I didn’t attend a formal care conference with her sons initially. But I will attend future care conferences for Jolene with the family at the facility, if the family desires.”

The law firm’s founding attorney, Carol Applegate, along with their Medicaid Specialist, took a closer look at Jolene’s financial situation and collaborated with Diane. Based on their earlier interviews with the sons, Medicaid would likely be needed to pay the nursing home bill in the future. Because Jolene’s husband had recently passed, completing the estate plan and updating documents, such as the Power of Attorney, were vitally important. “Another attorney in our office and I went to visit Jolene to further assess her mental capacity, so we could be confident that she would understand the new Power of Attorney document that she would be signing,” notes Diane.” Prioritizing issues that need to be addressed immediately is so important.”

As part of her Elder Care Coordinator role, Diane also provided additional community, healthcare, and educational resources for Jolene and her family. “In my role, it’s very important to have a holistic and collaborative approach with all the team members in the firm as well as with our community partners,” Diane emphasized. “Building relationships and being an advocate for our clients and families is key so that clients can attain the best possible quality of life.”

From start to finish, Jolene’s residential transition took approximately two weeks. This meant several very long days for Diane, who was managing other Life Care Planning cases at the same time. But Diane doesn’t see it as a hardship, she sees her role in Life Care Planning as a very valuable service. “I have a tremendous passion for helping older adults and compassion for their situation,” Diane admits. “It’s the most meaningful work I could ever do.”