Patient Navigator Works with the Elderly and Their Children

Local advocate serves as liaison between hospitalized father and out-of-state children.

Patient Navigator was contacted by the adult daughter of an elderly man who was a patient at a top cancer hospital. She requested that our Houston-based navigator  Dr. Zorrilla accompany him to his oncologist appointments in order to relay information accurately between the oncology team, her father, and his family.  Serving as a liaison proved to be instrumental in optimizing this gentleman’s care during an unexpected hospitalization. He was unable to advocate for himself due to the nature of his condition. His adult children were unable to be at the bedside because they resided out-of-town. At their request, Dr. Zorrilla stepped in and was able to request an appropriate second opinion consult within the hospital which served to clearly identify the underlying problem and allow the patient to be discharged to home to be reunited with his wife.

The search for out-of-state Alzheimer’s care.

Joni’s mother lived in a faraway state with few medical facilities.  Mom’s assisted living facility was no longer able to manage her declining condition as she entered the final stages of Alzheimer’s.   Joni asked Patient Navigator to search for and screen facilities in the state where she lived that could accommodate her mother.  We prepared a list for Joni as well as guidelines to use when choosing a facility.  Mom will be moving home soon.

I want a better plan for Mom.

Lydia’s mother was deteriorating.  Dad had recently died and Mom’s world was in upheaval.  Lydia moved her mother across the country to be close to her.  Although Mom was in a well-regarded assisted living facility, Lydia felt there was no overall plan to improve Mom’s health and to make social resources available to her.  We found Mom a new geriatrician who diagnosed medication problems which may have contributed to her decline.  We worked with Lydia to develop an overall care plan so that nothing would fall through the cracks and her mother could enjoy a better quality of life.

I can’t manage my husband’s dementia care anymore.

Donna asked Patient Navigator to help find local resources and caregiving options.  She had been managing her husband’s dementia for six years.  Now that his disease had progressed to the later stages of Alzheimer’s disease, she finally agreed to get help.  We pre-screened for Donna several local in-home caregiving agencies.  We also provided her with extensive information on the disease, introduced her to adult day care options and many other resources and support groups.

Dad is in another state and needs help.

Tony’s Dad suffered from various ailments.  His father belonged to a Medicare Advantage plan an Tony was upset by treatments that were being denied.  Patient Navigator prepared Tony with questions and strategies to use during his next visit.  During Medicare open enrollment, we conducted a thorough review of Dad’s Medicare options and moved him into traditional Medicare A and B, with a Medigap supplement and a Part D drug plan.  Tony was relieved that Dad would no longer be denied treatments and very happy to leave the private Medicare insurer’s plan.

Mom is moving and she needs a new oncologist.

Helen’s mother had cancer and was living in another state. Although elderly, mom was still working, using a combination of private and Medicare insurance. Our client asked for our help to decipher Medicare and Social Security Disability options as well as choosing private insurance supplementary medical insurance. We also conducted an in-depth doctor search to prepare for the mother’s relocation to her daughter’s state. A new medical team was ready to meet Mom as soon as she relocated, much to the relief of her family. They are pleased with their new doctor and medical team.

Where’s the best place for Dad to go?

Derek asked for our help in finding a long-term facility for his dad with multiple sclerosis.  After Dad’s most recent hospitalization, the family realized it could no longer manage his care.  Patient Navigator conducted a thorough nursing home search, spoke to multiple admissions offices, prepared a matrix comparing choices and guided the family through the decision-making process.  Derek thanked Patient Navigator for “helping us through this overwhelming and complicated situation to find the best care for Dad.”

Implementing a roadmap when the doctors don’t help.

Frank was diagnosed with multiple myeloma, but his oncologist did very little to explain the disease or set up support services. Frank and his wife were overwhelmed by the sudden onslaught of tests, doctors, medical bills and physical disabilities; they received virtually no guidance or help from the medical team.  When Patient Navigator became involved, we explained what home health services were available and arranged for their delivery, set up the client’s online Medicare account, helped to organize his medications and explained how his treatments would be covered.  Once we set things up to operate smoothly, the couple felt reassured and equipped to move forward with treatment.

Sandi needed urgent help for her distant grandmother.

Sandi’s grandmother, who still lived alone in another state, was found wandering in her hometown and taken to the hospital.  Sandi was called to come and take her grandmother home with her. However, her grandmother had advanced Alzheimer’s and Sandi quickly realized she could not provide the intense care and attention that was needed. Moreover, since her grandmother had always been a fiercely private person, Sandi had no information on Grandma’s health, insurance or financial records.

Patient Navigator spent hours with the family to sort through and organize boxes of papers to determine which records were relevant.  Once her insurance coverage and care requirements were determined, Patient Navigator researched facilities in both Sandi’s state and her grandmother’s home state that could accept a high-need, Medicaid patient immediately.  We explained to the family the process to transfer her Medicaid coverage from one state to another. Patient Navigator provided Sandi and her family with help, information and guidance during an exceedingly difficult and stressful time.  The family was able to make difficult decisions with more confidence and knowledge.“They guided us every step of the way through the very difficult process of what to do about care for my grandmother. They have a wealth of knowledge and expertise and provided it in a loving, caring way.”

Peter’s father needed answers, and fast.

Peter contacted Patient Navigator on behalf of his 80 year-old father who was recently diagnosed with metastatic gastric cancer in order to see what treatment options were available as well as to try to obtain test results (receptor status) from the treating hospital. Patient Navigator performed a literature search and presented the family with the latest options and obtained the results from the physician’s office within two days of consultation.

Tony’s Father Needed Better Care After a Stroke

Tony’s dad, who had a history of Parkinson’s but was able to care for himself at home, suffered a hemorrhagic stroke. After hospitalization, he was transferred to a skilled nursing facility near home for physical rehabilitation.  The eventual goal was intense therapy at a well-respected stroke rehab facility. There were problems with medication management as well as physical therapy at the initial skilled nursing facility and patient was not making progress. Patient Navigator was contacted to intervene to secure better care. Productive calls to a new neurologist were made and transfer to another skilled nursing facility resulted in a better clinical scenario for the patient and his family, both on an emotional and physical level. Patient Navigator was also able to reschedule an appointment with a new specialist one month earlier than originally scheduled.

Two failed hip replacements leave patient with special needs.

Mike suffered from peripheral neuropathy, and subsequently had two failed hip replacements. The second replacement was removed, leaving him with only one hip, the inability to walk, and chronic pain. Patient Navigator prepared questions for him to ask his surgeon about best next steps, and helped analyze his options. Facing imminent discharge from a convalescent facility following the hip removal, he also quickly needed help finding where to go next. After meeting with the convalescent facility staff, Patient Navigator researched local assisted living and board and care facilities that could both accommodate his special needs and be affordable, and summarized his best options.

Kaitlin’s middle-aged mother was diagnosed with early-onset Alzheimer’s disease.

She had been living with her husband in a remote area, but now needed more care than he could provide. Kaitlin asked Patient Navigator to research assisted living facilities with special dementia services, in three geographic locations where her parents thought they might move. Patient Navigator used many different resources, including personal contacts, to screen dozens of facilities. That list was further refined by thorough phone screening interviews with their staffs to determine if each might be a good fit for Kaitlin’s mom. By eliminating those facilities that would not be a good fit or that might provide substandard care before in-person visits, Patient Navigator saved the family a great deal of time, money and effort in their search for the appropriate new home for Kaitlin’s mom.

Patient Navigator successfully appealed a denial to obtain additional insurance coverage for an extended stay in a nursing home.

Melinda’s mother had already spent over 100 days in the nursing home and had exhausted Medicare’s coverage.  However, when Patient Navigator reviewed the nursing home’s  submission to the secondary insurer requesting additional coverage, we discovered several key documents were missing.  Patient Navigator helped the social worker prepare a proper and complete request.  Since then, under Patient Navigator’s supervision, Melinda’s mother has been given three extensions totaling over 105 days, covered fully by insurance.

Sally’s husband was in the final stages of congestive heart failure when she contacted Patient Navigator.

Sally was very upset with his nursing home and asked us to intervene. When her husband was re-hospitalized, Patient Navigator stayed with the couple, helping to communicate with doctors and manage administrative and nursing care issues. We persuaded Sally to consider hospice as an alternative to a painful hospital stay. Sally was initially reluctant but was ultimately glad that she was able to bring her husband home.

Helene was overwhelmed and anxious about her upcoming hip replacement surgery.

She asked Patient Navigator to manage the pre-op procedures and administrative requirements.  Helene’s navigator coached her through the surgery and rehabilitation. We organized her medical and medication information into useable spreadsheets which she has learned to use.

Eric was very worried about his 58-year old father in Washington D.C.

Dad began to experience sudden and severe deterioration of his physical and mental health early in 2010, including dramatic cognitive changes. Debilitating depression and anxiety paralyzed him even as other medical problems emerged. Eric contacted Patient Navigator in August 2010 for help. We got to work building a medical team including an internist, neurologist, neuropsychologist, endocrinologist, psychiatrist, sedation dentist and podiatrist. Throughout the process, we wrote concise medical summaries that the team appreciated. Patient Navigator accompanied Eric’s dad to 29 medical appointments and tests, wrote detailed summaries for Eric, made sure the doctors communicated, deciphered insurance issues, filed appeals, interviewed daytime companions and worked with the disability claims adjuster. Eric has expressed his “gratitude to Patient Navigator for providing services that were absolutely essential in creating my father’s recovery plan.”

Laura, who lived out of state, was worried about her aging father who had recently moved to an assisted living home.

Patient Navigator provided a package of information on geriatric depression and arranged for mental health services through private and county social services.  A Navigator visited regularly with Laura’s dad to help him transition to his new home.  “All I can say is WOW! Great job! It’s so comforting to know there’s someone there advocating for Dad. Once again, thanks for all you’re doing.”

Karen, a busy young professional, was overwhelmed with the demands of managing her aunt’s care and medical affairs.

Patient Navigator provided help to Karen journey with her aunt through diagnosis and treatment, researching hospitals and nursing homes, unraveling Aunt Mildred’s Medicare statements and doctor bills, and counseling. We accompanied Karen to doctor and nursing home visits. When her aunt passed away, Karen said “Patient Navigator helped me through one of the most difficult times in my life. They provided expert help in all stages: diagnosis and treatment, facilities including hospitals and nursing homes, insurance, bills, and counseling. I am deeply grateful for all of their assistance.”

Jennifer lived overseas and called Patient Navigator for help with her elderly parents.

.Her parents lived in a remote area of Florida. To deal with her mother’s increasing dementia, Jennifer had to travel back to the U.S. to explore new arrangements for her care. Patient Navigator researched a list of doctors and specialists, made appointments, and arranged for tours of facilities. That way, when Jennifer arrived in Florida, she hit the ground running, and made good choices for her parents.

Edith called Patient Navigator for help with her out-of-state mother, who had Alzheimer’s and lung cancer.

She needed our help moving her mother to Virginia. Patient Navigator researched local facilities equipped for Alzheimer’s patients, proposed a team of new local doctors and prepared a briefing book to help educate Edith on the disease and local resources to help her. We accompanied Edith to visit various facilities before the family made its choice.

Madeleine was looking for a part-time live-in caregiver for her mother with dementia.

She asked Patient Navigator to help her with her search. Since the job offered free housing in exchange for weekend work, Patient Navigator suggested seeking nursing students through local medical schools. Patient Navigator pre-screened several applicants for Madeleine who was then able to decide quickly on the right person for the job.

George wanted help organizing his medical records and designing a nutrition and exercise wellness plan.

Patient Navigator gave George a plan he could follow.  Although he is a healthy 71-year old widower, George had no immediate family nearby and was reassured that his Navigator was available if he needed her.