Most people don't think about care coordination until something unexpected happens.
For Frank Martines, it was a hip surgery. For his wife Monica, it was several serious falls.
Fortunately, they had a care coordinator who arranged for a caregiver to come in to prepare meals and help Frank recover. That meant Monica could leave the house without worrying while he healed. Then, when Monica was released from the hospital, Frank didn’t have to worry about managing the treatment plan and all the physical therapy appointments that followed.
“I felt so well taken care of,” Monica said. “I didn’t have to worry about what was going to happen next.”
The people who plan best build their relationship with a care coordinator while they're healthy so they know who to call when they need more support.
A care coordinator connects your primary care physician, specialists and community resources into one coordinated care plan designed to support you now and as your needs change. At Kendal at Home, care coordinators are your main point of starting the day you join.
They become a trusted partner who gets to know you and your goals, helps you stay healthy with proactive planning and assessments, and steps in to arrange for services when you need them.
Kendal at Home care coordinators take a proactive approach to helping older adults stay healthy and independent, avoiding injury and the need for care as long as possible. Here’s how.
One of the first things your care coordinator does is get to know you as a person and your health as it is today. That starts with physical, cognitive, and nutrition assessments that build a clearer picture of your overall wellness.
From there, they’ll connect you with resources to help you stay in shape and stay sharp. That might mean pairing you with a personal trainer and helping you set health and fitness goals. It could also include making sure you’re keeping up with preventive care, including annual wellness visits, recommended health screenings, and routine bloodwork. Because they build a relationship with you and see you at your best, they’re more likely to notice small changes early.
Your care coordinator will also check in monthly, or as often as you like, in whatever way works for you. That might be as simple as a text when you’re heading out of town for a trip and letting them know where you’ll be, Kendal at Home care coordinator Pat Murray said.
Falls are the leading cause of injury among adults 65 and older, according to the Centers for Disease Control and Prevention.
Kendal at Home Care Coordinators conduct fall prevention assessments to identify risks related to balance, vision and the home environment. Your care coordinator works with you to turn those findings into action. They will recommend practical changes, connect you with the appropriate resources and services, and follow up as your needs change so can stay safer and more confident at home.
If you do experience a fall or an injury, your care coordinator will work closely with your doctors to ensure you have everything you need to heal at home and receive follow-up care to help you fully recover.
As prescriptions change over time, it can be more difficult to keep track of dosages, refill schedules and potential drug interactions. Even a single medication error can lead to an emergency room visit. Your care coordinator helps you stay informed by reviewing medication updates with you, helping ensure changes are communicated among your providers and caregivers, and providing an additional set of eyes during times of transition.
Managing healthcare today often means coordinating between primary care physicians, multiple specialists, therapists, home care providers and family members. Without someone overseeing the big picture, important details can be overlooked. Your care coordinator serves as a central point of contact, guided by the three Cs of successful care coordination:
By coordinating services and communicating across your care team, Kendal at Home care coordinators reduce the burden on older adults and their families.
Successful recoveries often begin before you leave the hospital. Kendal at Home care coordinators work with hospital discharge planning and arrange services and support needed for a safe transition home, whether after an unexpected hospitalization or a planned procedure (such as a knee replacement or cataract surgery). For example, when one member broke both wrists and a knee while on vacation, her Kendal at Home care coordinator arranged for a hospital bed on the main floor of her home and coordinated in-home caregiving so she could recover safely at home instead of remaining in the hospital.
Another member had a hip fracture that required a hospital stay and rehabilitation. While the services she received from the hospital ended after she hit her milestones, she knew she would need more assistance with activities like grocery shopping and preparing meals when she returned home.
Her care coordinator arranged for someone to come in and help her with those parts of her daily routine.
This type of support can be helpful even after a planned surgery, such as a knee replacement.
Through coordinating equipment, home care, and follow-up services before discharge, care coordinators allow members to return home with the support they need while reducing unnecessary delays and complications in recovery.
Planning ahead means more than completing legal documents. It’s making sure the right people, including your medical power of attorney, a trusted family member, and your care team, know your wishes and are ready to act on them.
Because your care coordinator has developed a relationship with you over time, they are familiar with your goals, values, and documented wishes. Though they aren’t a power of attorney and don’t have the authority to make medical or legal decisions on your behalf, they can communicate with those who are legally authorized.
Frank and Monica admitted they never thought they would need a care coordinator, but they’ve had someone to help them recover each time one of them has been in the hospital.
Because someone was there to arrange for a physical therapist and someone to help with things like laundry and cooking, the other didn’t have to shoulder the burden of caring for the other while running the household alone.
They continue to work with a personal trainer and take classes to improve their balance.
“We were very, very happy with the fact that we made the decision years ago,” Frank said. “From our perspective, it’s paid off many-fold.
The best time to build a relationship with a care coordinator is while you’re healthy and able to make choices on your own terms.
Care coordination and care coverage begin the day you become a member, so if something unexpected happens, you don’t have to scramble to find care in a stressful situation or worry about whether a long-term care policy will cover it.
You’ll just make one call to your care coordinator, and they’ll make sure everything is covered, from the care you need to recover to helping you maintain the everyday things you love about your life.
Take our 20-Question Care Planning Assessment to see where your care plan is solid and where there are gaps. Then, talk to a Kendal at Home member advisor about next steps.
Care coordination is the process of organizing healthcare, support services, and community resources to help older adults safely remain independent. A care coordinator works with healthcare providers, caregivers, and family members to create a personalized care plan that evolves as needs change.
They serve as a trusted guide for members, helping manage everything from health monitoring and medication management to home safety, hospital discharge planning, and in-home care. They also coordinate communication among providers and connect members with the services and community resources they need.
The three Cs of effective care coordination are communication, continuity, and collaboration. Care coordinators keep everyone informed, keep care consistent during health transitions, and bring together healthcare providers, caregivers, and support services around each member’s goals.
Care coordination is also commonly called care management, care navigation, or a coordinated care plan. Whatever the term, the goal is the same: helping older adults receive the right care at the right time while staying in control.