The Family Nurse: Hospitals handing off medical care to family caregivers

“43.5 million adult family caregivers care for someone 50+ years of age,” according to the 2011 Alzheimer’s Disease Facts and Figures. PBS recently aired a story on the long-term demands of caregivers that provides a snapshot of what it looks like to be a family caregiver in the United States. It is often a fall or illness that triggers family caregiving, which makes the transition from the hospital the starting point of a long and difficult journey. Transitions can be one of the most dangerous times for aging adults as environment, medications, living arrangements, needs and abilities are all in flux. It is the adult children and family members that are shouldering most of the burden to make the transition and care at home as smooth as possible, but the learning curve is steep and many are unprepared for the care they are suddenly responsible to provide. As the PBS special highlighted, “Americans are being released from hospitals quicker and sicker. That’s put new demands on the family members who care for them.”

In the Home Alone Study- a study of family caregivers who provide chronic care- found that nearly half of the caregivers surveyed performed medical and nursing tasks. More than 96% also provided activities of daily living supports such as personal hygiene, toileting, dressing, taking medications, shopping, transportation, etc. The type of tasks that informal caregivers are providing is becoming increasingly complex, especially as people are living longer. Care may include cleaning feeding tubes, checking blood sugar, managing or administering medications, cleaning catheters, etc. What is more striking than the tasks themselves is the fact that family members are having to learn these tasks admittedly by trial and error and do not receive any training for this type of work.

 Adult children are wearing many hats and often serve as nurse, personal assistant, taxi service, nutritionist, pharmacists, companion, healthcare advocate, financial advisor, and more. It is difficult to remember what it felt like just to be family. Outside of the walls of a hospital, is an entire system of improvised health care that is being administered by family members, many of which are professionals in other fields. Judges, teachers, attorneys, entrepreneurs, are often ending the work day and beginning another job when they return home. There is a steep learning curve when it comes to elder care, from medications, to chronic disease management, to powers of attorney. As the needs and prevalence of elder care rises, there is one important professional who is standing in the gap between hospitals and home: Geriatric Care Managers. These certified professionals come from a range of backgrounds including Registered Nurses and Masters of Social Work. Their expertise in the care of aging adults make them an extraordinary asset in an increasingly aging society and an increasingly complex health care system.

When you get the call that a parent is being discharged from the hospital, a multitude of questions come to mind and it is important that you know who to call to help find the answers:

  • Can they live safely by themselves?
  • Should I move them into my home?
  • Do I need to make changes to their home?
  • Will they need continuing therapy?
  • Who will make sure they’re taking their new medications properly?
  • Who will do the grocery shopping and help dad make meals?
  • Who is going to drive mom to her appointments?
  • What if something happens in the night?

A Geriatric Care Manager is equipped to take a holistic look at the care needs and devise a plan of care that scopes out the full needs of a loved one in great detail. From that moment of transition in the hospital, they are able to coordinate between primary care doctors specialists, therapists, and other professionals involved to provide simplified and consistent communication to family whether they be long-distance or in the area. As advocates that work for the client, they can ensure the patient’s interests and wishes are respected and that they receive the best possible care. In preparation for a return home, they can also do an environmental inventory of the home to assess the safety and recommend changes to accommodate new needs. As RN’s they are able to set up new medications in advance and make sure that loved ones either understand the changes, or have professional assistance administering medications properly. If long or short –term help is needed within the home, they are also able to arrange certified nursing assistants to attend to daily needs such as meal preparation, dressing and grooming assistance, and general home making responsibilities.

Having a professional’s eyes and ears in the situation can be a huge relief for adult children as they do not have to bear the full burden of responsibility for the well-being and safety of their loved one. Having the logistical and expert input and help allows for increased safety and decreased stress for everyone involved. As a private service, it doesn’t have to end after the transitions. Care Managers can continually assess loved ones for changes in care and needs to make proactive recommendations. As a neutral third party, it is often easier for aging adults to hear recommendations coming from a professional rather than a family member.

The good news is that while Care Managers are making transitions easy and reducing the risk of readmission to the hospital, you don’t have to wait for a crisis to start the elder care conversation. At Sound Options our Geriatric Care s provide elder care coaching to help families plan for the future and make good choices before they are needed. By shifting the conversation from around the hospital bed to around the table, they are helping families engage difficult conversations outside of crisis mode. For more information about how Geriatric Care Management or Home Care could help your loved one transition from hospital to home, visit us online at 800.628.7649 or visit us online at

View Full PBS Story Here:


Published on April 10, 2014.