Episode 57
The anatomy of care management: Angela Daniel’s guide to personalized care
Erin Vallier:
Welcome to another episode of the Home Health 360 podcast, where we speak to home-based care professionals from around the globe. I’m your host, Erin Vallier, and today I am joined by a dear friend and someone that I respect and admire, Angela Daniel. She’s been a nurse for over 30 years and, as you can imagine, she’s got a wide range of experience. She started off with the adrenaline rush of the emergency room and somehow ended up working on a cruise ship. Now I’ve got to hear that story one day, because I’m sure it’s good. Angela has served as director of professional services for Georgia Medicaid. She’s been a college professor of nursing, a home care operations officer and an area VP of clinical services. Presently, she serves as an aging life nurse care manager and helps clients and families navigate our complex healthcare system for the best healthcare and lifestyle outcomes. Welcome to the show, angela.
Angela Daniel:
Oh, thank you so much, Erin. It’s such a pleasure to be here. I really appreciate the time and the opportunity to share knowledge and my experiences with care management and home care to your audiences.
Erin Vallier:
I love it. When chatting with you to get ready for this episode, it was pretty apparent to me that, depending on who you talk to, they have a completely different definition of care management and I think even in the different settings you’ve worked, you have evolved your definition of care management. If you wouldn’t mind, would you please share with the audience what it is? What have you learned about care management?
Angela Daniel:
over the years, certainly so. Healthcare in general has always been very complex, even when it was in the early 1900s and we really didn’t know as much as we know now. Mom or dad or somebody would have a health issue and the doctor would come in and sometimes it would get fixed. Sometimes it wouldn’t, but it could be a whole journey and you would start the process of trying to find out what was wrong, how you could make it right and how to keep mom or dad or the family member comfortable. So actually case management, which is the older sister of care management, started in the 1920s and it was mainly focused toward mental health, psychiatric care, and was done by social workers, and nurses have a small part in it. It was focused as being an advocate, coordinating care and getting the nuts and bolts of a client’s care done, making sure that the appointments were made, that you had the right practitioners and you were able to get that illness treated. So in the I would say, a little bit later on 60s, 70s, then care management kind of came into play. A big driver of this was insurance, because in our capitated world then the push was to get care completed quicker, more efficiently, to have better outcomes so that the providers could see more patients and help them on their journey. So care management was actually thought of as a team-based, patient-centered process designed to look at outcomes and then goals and see how you could make those come together. It is something that, through my lifespan, has had its ups and downs, because care management, as we think about it when we talk about my day a little bit later on, you’ll go wow, you did some really simple stuff there and then you did some really kick-butt stuff there it’s something that is very individualized and it’s very difficult to get done right. When you talk about care management, we really talk about a spectrum and it truly is holistic. You look at the families, you look at the client themselves, the resources, community coordination and how all of that impacts the patient or the client and how you’re going to move them toward the goal of the best outcome. It might not be your best outcome, but it will be their best outcome, what they choose.
Erin Vallier:
I didn’t realize that it has been around since the 60s 70s is what you said as a team sport. I know it’s gotten a lot of buzz here lately because we’re trying to give the end user of the healthcare system so the patient themselves which navigating the system is completely frustrating I know that firsthand and then also improve outcomes shorten the length of stay or streamline everything and improve outcomes. Have you seen this in your practice?
Angela Daniel:
So when you have a care manager that’s working with the client and there’s actually there’s a couple of different types of care managers. So, from my practice, I started out as a geriatric care manager. Now, geriatric care managers mainly focus with, obviously, a geriatric population and they’ve really noticed a boom in recent history and recent past because that population is aging and they require more services and we really need to focus on how to be efficient with those services but also recognize that these are humans that we’re dealing with. They’re not just modules that you can stick a widget in and move on from point A to point B. There’s a lot of dynamics that go into play to be successful. The geriatric care manager is one type of care management and then there’s the aging life care manager, which actually is what I am, and I work with clients across the spectrum. So I’ve got a 20 year old, I’ve got a seven year old and then I’ve got a 92 year old. Now your goals are the same as a geriatric care manager, an aging life care manager and I’m a little bit biased because, as a nurse, I think nurses are great. So there is the nurse care manager, which is just a subcategory. You can be a geriatric care manager or an aging life care manager, but with the nurse care managers, then what you get is you get someone who has that medical knowledge. They have the ability to understand the community resources, to look at multiple different impacts on the client, the family. There is the mental health knowledge. There’s the ability to just look at it not only holistically from the client standpoint, but holistically from the practitioner standpoint, from the home health care provider standpoint, from the client standpoint, from the family standpoint, because as nurses that’s what we’re taught to do. We look at everything from so many different angles. So my goal as a nurse and a care manager is to make sure that client stays in their location that they want to be in. If it’s their home, it’s their home. If it’s their assisted living, it’s their assisted living. But essentially the services that we bring in, they go uninterrupted. So if we can find that great home care provider and have the aides get in place and they’re there for eight hours a day, five days a week, I don’t want that to stop because I know as a home care provider, once I stop services for my client, if they’re in the hospital or if they have a setback or they go to rehab, then those aides they move on. They don’t stay with my client. So my goal is to make sure that my client stays out of the hospital, stays in the home, is able to get the services that they need, that we kind of get ahead of any problems and we make sure that all of the players and the stakeholders that are involved with their care are on the same page.
Erin Vallier:
You’re like the orchestrator of all of the healthcare and just make sure that there’s consistency, and I love it that the nurse can bring that clinical perspective into the mix and really help to make sure that those services are seamless. You said some things in there. You’ve got a bunch of different kinds of care management is what you were talking about. So how is the nurse piece, the nurse care manager, different from these other types of care management programs on the market today?
Angela Daniel:
As a care manager, you can really say that you’re a care manager without any certification, without any prior knowledge, and obviously you wouldn’t want to go with someone who says that they’re a care manager and they don’t have credentials or knowledge or to be able to know exactly what they’re doing. But for care managers, then usually they are social workers and they are people who are in the elder care community and they have specialized knowledge, especially the geriatric care managers. You don’t have to be a nurse to be a care manager, but I think for clients with complex health issues and with complex needs in general, then that nurse care manager gives you that expertise, that broad spectrum of being able to intervene at multiple points and, for example, I have to be knowledgeable of mental health and family dynamics and some of the things that we talked about before and how to navigate that mind field. That goes along with understanding what’s coming from the medical perspective. How are all of these client issues that might be medically driven? How is that impacting the client? How is it impacting the family? What do we see? When someone has dementia and thinks that the sky is green and there’s a monkey flying through it, because the family’s? Oh my gosh, this isn’t mom. That’s okay. I agree this isn’t the mom that you have known for a very long time, but we have to look at the situation we’re in now. What’s our goal? What outcome do we want? And that may be just to help you live a more full life with mom in her situation and her status that she’s experiencing right now that makes sense.
Erin Vallier:
So I can imagine you said a social worker they could navigate parts of that pretty well. They’ve got the family dynamics and all of that stuff. But when it comes to seeing things and art there and having to navigate all of the medical stuff, they might be a little over their head. So I can definitely see the benefit of having a nurse in this particular role and you’ve partially answered what my next question I think would be is really who’s going to benefit from having a nurse care manager or their specific types? You spoke about one really complex dementia. Talk to me about other types of clients that might benefit from this.
Angela Daniel:
So the types of clients that really benefit from nurse care management are those that are, like we talked about, complex. So complexity doesn’t necessarily just mean that they’ve got multiple comorbidities or they’ve got multiple chronic illnesses. It may mean that they might not have a lot of money. They may have a special needs trust, they may need specialized services that the regular medical system isn’t able to provide. So we need to look for places that may be able to provide them and to get them there. I have clients that are psychiatric clients and our mental health and everybody on your podcast probably recognizes our mental health system is in desperate and dire shape right now. So trying to find the help that people need is an area where a care manager and a nurse care manager is really good, because you have to balance your medications. You have to balance the way the caregivers are working with the client and the family is working with the client. So it’s going to be those clients that really need more and I use air quotes around more, because families do such a fabulous job of taking care of their mom or their dad or whoever the client is. But you don’t know what you don’t know until you figure out, you don’t know it and you’re already five steps down the path and you’re like, oh, if I had known this six steps ago then we would have chosen a whole different path. I call myself the dot connector. I’m the resource guide. I’m the person that will hold your hand and sometimes drag you along into an outcome that you say you want. And it might be a little bit painful getting there. We might have to stop pain medicines, we may have to make some changes, we may have to do some things that are uncomfortable, but the main benefit of a nurse, care manager and a care manager in general is that we build a relationship with the client, we build a relationship with the family and we build a relationship with the people that interact with that client and family so that we’re able to really guide and be that cog in the wheel that can see what they need and then advocate for it. And sometimes we have to advocate within the family because everybody has a different idea of what may be best or what may be right. And that’s a big part of my job is being referee and I’ll always say I hear what you’re saying.
Erin Vallier:
I think what you mean is You’re the glue that holds it all together for the client, and I think what I heard you say is in terms of who’s going to benefit from this. Complex doesn’t necessarily just mean the medical diagnosis. They might have some financial circumstance or a complicated family circumstance or some geography or other things that are hard to overcome and try to figure out on your own, and those are the kinds of clients that are going to really benefit from a nurse care manager. Well, let’s think about this from an agency standpoint. Earlier, we just briefly mentioned that it’s supposed to improve outcomes, and that’s where reimbursement is going right. We all want better outcomes, not just for the reimbursement, but it’s because what we do is to make sure that people have good outcomes. If I’m an agency and I am going to implement a nurse care manager, what might I expect in my business in terms of client satisfaction, outcome scores and stuff like that?
Angela Daniel:
The benefit of implementing a nurse care manager or care management strategies into your business is that by the culture change and shift that comes along with that, then you are building relationships with your clients. You are able to understand them a little bit better, ask more pointed questions, be able to see what they need and how you can offer a solution to that problem. You can also use that as a training and an educational tool. You see a lot of patterns in care management that people experience a lot of the same problems, just like you in home care. You know that when you walk in you need to do X, Y and Z and that the assessment process needs to look like A, B and C and that way you get the information. But by implementing some of the techniques for care management and if you have a nurse and a higher level of nurse care management, then it really can get consistency with your clients. Because I have clients that I have had for three years and watched them through the life cycle and to been able to make sure that they stayed strong and they stayed healthy and they’ve had like home care. They’ve had home care for two and a half years and the same aids have stayed with them for two and a half years. It has been beautiful. I can’t say enough about that, because home care has been an integral part to being able to make them move toward those best outcomes, Part of getting the scores for the home care. When you talk to the clients, If you have that relationship with them, then they’re going to be happier with you. If you’ve got the ability to help the aides understand what they need to do and how they can best serve their client and how they can build that relationship, then it is really only a benefit to the agency and the clients themselves, because it’s that relationship that is key in life in general. That’s what I tell my kids. It’s not necessarily what you know in life, but it’s who you know and how you can help them find solutions. That’s well stated.
Erin Vallier:
So continuity of care is where really there’s a big benefit, is what I’m hearing. We all know that when you have a continuous set of caregivers, they just provide good care, instead of having a revolving door of a new aid coming in every single week. I think, if I’m understanding correctly, you just make sure that’s a possibility for people who really need it. It sounds like a fun job.
Angela Daniel:
It actually is the most fun job I have ever had in my life and it even beats the cruise ship, because the cruise ship had its benefits. Don’t get me wrong. The cruise ship definitely had its benefits, but I get to really understand people and see it’s almost like instant gratification. When you get this right, then you see someone’s life get better. You see them being able to have a better outcome, be able to stay where they want to. It’s also probably one of the hardest jobs I’ve ever had in my life.
Erin Vallier:
Let’s dive into that piece. You’ve said a couple of things that stuck out to me. You work across the whole spectrum, the whole continuum of care, and it’s really important to get it right. See the outcome, the good outcome. Tell me, what does that actually look like for?
Angela Daniel:
you. It’s a normal day and I use air quotes around normal because that is rarely in healthcare home care, home health, you name it. If we’re working with people, then normal is on a spectrum. It started out that morning with meeting a family at a memory care center. They’re going to transition their loved one from one memory care to another one and the nurse had to come in and do the assessment. I was there to make sure that everything went smoothly, that the information was transitioned properly, that if there were any questions that may be difficult or could be answered in a better way, then we wanted to make sure that we answered them in a way where the best information was given and it couldn’t be seen as negative. Now, some things are just negative. They’re going to be negatives, but we just want to make sure that we’re giving the best answers and truthful answers. Then one of my clients needed to have home care. We was talking to them. I have a piece of paper that I give. Since I worked in home care for so long, I know the things that home care will do and the things that the clients will find helpful or those nuances, because when you go in and you talk to someone then well, yeah, the aid can do this, the aid can do this, but if you’ve got it written down it’s a check sheet it’s okay, we need them to do this, we need them to do this, and then we can formalize that and say what are the special things around this that you want the aid to do, what are the things, so that it’s there, it’s in writing and then the aides can look back at it and refer to it. I had worked with the client to get that in place, called the home care company and made sure that they knew what we needed, what were the major targets that we needed, and we could start the search for that, get the service agreement sent out, be able to start that process. I worked with a client about her insurance so right now we’re in open enrollment and she transitioned from Medicaid to Medicare and needed to find out if she was on a Medicare Advantage plan. Because if you’re on a Medicare Advantage plan then we can make appointments at the dentist and we can make vision appointments and know that they’re going to be covered. But we need to find the right providers. We need to make sure that you are in your area, that we’re doing what we need to do to make sure that the insurance requirements are being met. And she also has Q&B, so understanding how the qualified Medicare beneficiary plays into Medicaid was a thing that we had to talk about. And would she be responsible for any charges or what to expect? Had a psychiatric client that was ready for discharge. He’s been in the acute care psychiatric community for eight or 10 weeks now and he had outbursts seven days ago. So I said I need to talk to the doctor so that we can understand what has changed so that we won’t have another violent outburst, because when he goes back to the memory care center then they will want to know if he has had any violent outbursts. Is he compliant with his meds? So ensuring that we had that conversation was on the list. I’ve got a 93-year-old woman. Love Ms Jones, she is so sweet, she’s just got my heart. But Ms Jones doesn’t go grocery shopping. She doesn’t do anything. I make sure that I go buy and I do her medication organizer every week and picked up groceries for her and assessed her for any cognitive status changes, because she has dementia and we want to make sure that she’s not more confused or because you always worry about there’s a UTI kind of lurking someplace, or there could be a pneumonia, and this is the things that I recognize because I see her very often and she doesn’t necessarily have the family support to get there very often during the week. And then there were a couple of fights with a pharmacy in a doctor’s office to get the refills called in or the freestyle Libre order with the appropriate diagnosis code put on it so that we could get insurance to pay for it, and those are ongoing. It seems like there’s always a finger to put in the dam or go into the dyke and try to stop it so we can get something done and then look toward the long term. And then a few phone calls sprinkled in with crisis or I need money transferred into my account from the special trust manager saying I need to get my hair done. So just lots of texting, a lot.
Erin Vallier:
There’s a whole rainbow of different things that you have to do in one particular day. How do you keep yourself organized? Are you using any piece of technology?
Angela Daniel:
We have a software program that’s our EMR and care management so that we can essentially do our documenting daily, and then it’s also a billing tool. It really becomes even more clear to me once you work in the healthcare world that you need to have an EMR that is able to be flexible, to fit what you need for your clients and to be able to work effectively. And then I used to carry around a notebook and it was one of those cute notebooks that had a saying on it hang on, tomorrow is going to be better, or please, lord, help me. And so I used to just keep by day when I would do something, that I would jot it down, and then that night I would try to go back and be really organized and then be able to document in my clients files. But it ended up that I was never as efficient and as organized as I wanted to. I seem to get a lot of stuff done, but I’m just not efficient with documenting it, and so I actually keep individual client files now on an electronic like an iPad or a remarkable, and so when I do something I’ll document in their file for that time. So it makes the actual EMR documentation much more easy.
Erin Vallier:
Okay, that’s a lot of layers of documentation, so definitely it sounds like technology is a must have. So if I’m an agency owner, listening to this podcast and I’m thinking this sounds like something that’s calling to me, I want to investigate this a little bit further. How might they begin to think about implementing something like a nurse care manager?
Angela Daniel:
Yeah, some home care agencies have nurse care managers in place. They are usually the home care agencies that handle and specialize in the really complex cases like the paraplegics, the quads, the brain injury clients, because essentially those clients are so complex and if that’s your kind of bread and butter then it really benefits you to have that. If you wanted to start a care management program, I usually tell people that in the beginning it’s better to actually find care managers, find an Angela that you enjoy working with and build that relationship with them so that you can understand that process, see the benefits of it and then be able to target what you think is important for your agency to start with. For example, you can go to the Aging Life Care Association website, alkaorg, and it will tell you, in your area or your zip codes, who are the geriatric care managers, the aging life care managers that are certified. So that goes back to the point of making sure that you find an agency or a care manager that is able to be effective and knows what they’re doing. So I’m one of those folks that loves education, so I’ve got lots of letters behind my name and it doesn’t really matter, except if I’m able to make an impact in someone’s life and it’s through that information and knowledge that I’ve acquired that I can do that. My first kind of thought is in the beginning, you’re jumping into the really deep end of the pool. If you want to start a care management program, I would partner with a care manager or find a couple of care managers that you can refer to and that they can refer to you, so that I use home care services probably more than any other service than with my clients. I have two or three home care companies, depending on the area of Atlanta, that my clients are in that really do a fabulous job, and so I know I can call up that home care operations person and, bam, I’ve got a situation that’s going to be a positive for the client and a positive for me. If you, working with a care manager and having those referrals and building that relationship is the first way that you can do it, you can start a care management program, but that’s like I said, you’re jumping into the deep end of the pool. What I really recommend clients doing if you really want to put something into place right now, is to evaluate your agency and see what are the outcomes that we see that we’re having problems with? Are our clients really struggling with not being able to call into the office, not having caregivers that meet their needs? What are the surveys telling us that we need to do? And then be able to work with someone to address those, to put a plan in place and get it so that you’re able to meet those client needs. Because it sounds really simple when you say we want to have a point of contact for 27 clients and it’s going to be this person and they’re going to make sure that the scheduling is right and they’re going to make sure that everything flows through and that if there’s a doctor’s appointment, that the aides know about it and where they need to be and what they need to do, and if there’s a medication problem, who’s the aides going to call, and it rolls on itself. There’s multiple layers and you want to make sure that you understand what your caregivers are really good at and what you need from them to be able to be more effective with your overall client process.
Erin Vallier:
Gotcha, that was a really nice explanation. So it sounds like there’s two paths, because the nature of what you do as a care manager, you’re a layer above the tops. You’ve got all the care. You’ve got the home care, you’ve got the home health, you’ve got the community services, you’ve got the doctor’s appointment and you’re just the layer above that is orchestrating it all, making sure it all happens without a hitch. And so if I’m an agency owner and I want to incorporate this into my offerings, the easy way is use that. There’s an online resource.
Angela Daniel:
What was the website it’s the Aging Life Care Association, so it’s alkaorg Alkaorg, okay.
Erin Vallier: So they can go there and they can find out who is in their area that does a nurse care management and then just start building that referral partnership. That would be the easy way. And then I liked what your advice was. If I’m going to do it myself and jump into the deep end of the pool, I should start with an internal evaluation of what my agency is really good at and what we’re really bad at. What are the gaps in our knowledge and gaps in our client satisfaction, gaps in our outcome? And then figuring out from there how you would want a nurse care manager to operate and then going about, obviously resourcing someone who has the right credentials, because you have to be credentialed to do this job. Did I catch that Right? Am I missing something?
Angela Daniel:
Okay, no, no. I think if you want to start a program internally, then you really need to understand your agency and what you bring to the table the good, the bad and the ugly and to be able to then find someone that is able to help you maximize the good and make sure the ugly is pulled up.
Erin Vallier:
So if somebody was interested in having a conversation about their organization and how they might go about implementing some of these techniques and tools that you’ve mentioned, would you be open to a conversation?
Angela Daniel:
Sure, I tell people that I have more opinions than anyone would ever want to recognize. I have more useless facts and knowledge roaming around in my brain than anyone would ever want to hear about. That’s one of the things that drew me to being a care manager is being able to help people. Now I have that background where, as a nurse, I’ve been a little schizophrenic. I went from the business arena to the teaching, to the education, to it’s just. I’ve been across the spectrum. I really feel like that. My strength, for example, is being able to look at a situation and then being able to find those to use a cliche out of the box answers. Sometimes that’s what it takes in a home care agency is your clients don’t live in a box, you don’t live in a box, so you have to find those answers and processes and goals that work for them. I think it’s just pretty cool being able to look at the different problems and challenges and positive aspects and knit together a solution. I’d be happy to have a conversation with anyone and share expertise or be able to help the organization.
Erin Vallier:
That’s fantastic. I know that just given your experience, you’d be a great resource. So how can people reach you?
Angela Daniel:
Can I get my cell phone number? Would I be doing myself a disservice?
Erin Vallier:
I wouldn’t do that Maybe a LinkedIn or an email or a website.
Angela Daniel:
I am on LinkedIn, so it’s Angela J Daniel on LinkedIn. You can also reach me at angela at ajdadvisorygroupcom, and then you can do an AJ24 at yahoocom. That’s the backup to the backup that everybody has had for about a million and a half years, but I am more than happy to share information or just answer questions.
Erin Vallier:
Fantastic, and we’ll make sure that information gets into the show notes so people can reach you if they’re curious. I really do appreciate you taking the time to talk to me today. I’ve learned quite a bit more. We’ve talked about care management a couple times, but I’ve learned quite a bit more today. I just appreciate you sharing your knowledge and wisdom with the folks that are listening today.
Angela Daniel:
You are too kind. Truly my pleasure and my honor, because I think that everyone in home care, in the medical profession, especially if it is your career, it’s a calling for us and we really want to make sure that people are taken care of, that they’re getting the best outcomes, and it’s just. It’s an honor and a blessing to be able to be part of people’s lives.
Jeff Howell:
Home Health 360 is presented by AlayaCare. First off, we want to thank our amazing guests and listeners. To get more episodes, you can go to alayacare. com/homehealth360 or search home health 360 on any of your favorite podcasting platforms. The easiest way to stay up to date on our new shows is to subscribe on Apple podcasts, Spotify or wherever you get your podcasts. We also have a newsletter you can sign up for on alayacare. com/homehealth360 to get alerts for new shows and more valuable content from AlayaCare right into your inbox. Thanks for listening and we’ll see you next time.
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Episode Description
Join seasoned nurse and care management expert Angela Daniel as she navigates the complex world of home health care. This insightful conversation explores the profound impact of care management on home health, the various types of care managers, and their unique roles in delivering personalized care. Angela discusses the benefits and challenges of incorporating a nurse care manager role, highlighting improved patient satisfaction and outcomes. She also guides listeners through the process of initiating a care management program, emphasizing the importance of fostering relationships with care managers. This episode is a valuable resource for those looking to integrate care management into their services.
