Advocate, broker, negotiator, manager, educator, analyst, problem-solver:  In a typical day, CICOA Care Manager Susan Wirthwein, MSW, LSW, fills each of these roles.

“I came to my career as a social worker later in life after having a personal experience with the healthcare system,” Susan says. “I saw that people need information and advocacy.  Now I do what it takes to help others navigate through that complex system. ”

“What it takes” begins with a compassionate heart and excellent organizational skills. On this particular day, Susan applies both to her morning paperwork and calls before setting out for an afternoon of client visits.

Empowering People

Her first stop is at the home of a 67-year-old homebound client and a daughter who lives with her.  Susan asks about new medications and the newest aide. Aide turnover can be stressful for an elderly client, so Susan listens to what the client says and watches for unspoken signs of stress. 

While in the home, Susan learns that the daughter is now handling her mother’s daily blood sugar check. Before she leaves, Susan encourages her client to get out of bed more often and to eat the daily meal CICOA’s Meals & More program provides. She also reviews the use of the emergency call system, which provides both mother and daughter peace of mind, knowing that emergency assistance is readily available at the touch of a button.

“We want not only to coordinate care, but also to empower people to actively participate in their own care,” Susan explains.

Like Susan, CICOA’s 49 care managers work hard to make sure the services they broker on behalf of nearly 2,800 clients are working.  One way they do this is through in-home assessments every 90 days, during which they ask clients about changes in their health and functional limitations, medication, recent falls, emergency room visits, and any hospitalizations or nursing facility stays.  They also review with the client their satisfaction with services and determine if their changing needs are being met. 

In addition to the 90 day visits, care managers conduct an annual assessment for each client to determine if state-funded care is justified and to review the services on the plan of care. State funding through CHOICE allows CICOA to place a variety of services in a client’s home.  Some examples of in-home services are:

• home health aides, who provide bathing and personal care
• attendants, who provide personal care and also can help with errands, meal preparation and other household duties
• homemakers,  who provide light housekeeping and laundry assistance
• nurses, if the client’s condition is more medically complex

Other service options available to help clients remain in their home or the community include personal emergency response systems, adult day services, respite care, home-delivered meals, equipment, and home and vehicle modifications that improve accessibility and safety.  

Hub of Care

Susan’s second stop is with an 82-year-old client and her adult son, and they discuss the amount of services required to meet the client’s increasing needs. Since she is bed bound, she needs assistance with most activities of daily living, including bathing, dressing, feeding, and moving her to prevent bed sores.  Susan recommends a small increase to the client’s care plan.

In addition to the 90-day and annual visits, a client may call at any time with questions or concerns. CICOA’s care managers address changes as they arise throughout the year, serve as a liaison between the client and provider to make sure the client’s unique needs are being met, and broker additional services as required.
 
“A lot of what we do is troubleshooting for our clients, working things out and connecting them with available community resources,” Susan says. “In many ways, we act as the hub of care.”

Anticipated Guest

While CICOA’s care managers monitor the wellbeing of their clients, they also become anticipated guests, especially for those without family nearby. That is the case at Susan’s last stop of the day.  The client lives alone and can quickly answer her questions about services, medications, falls and doctors’ visits. The last 20 minutes of the appointment are used listening to stories from the client’s past and talking about current events.  While these social visits are therapeutic, they also build trust between the client and care manager.

The home visits wrap up shortly after 4 p.m., yet Susan’s day is far from over. She returns to the office to file necessary reports, return emails and make additional calls. With an average case load of 65-70 clients, care managers have difficulty fitting everything into their work days.

 “I want to be a person who can help others. And I always want to provide the best care possible,” Susan says.  “People need advocates.”