In the fall of 1988, Generations provided a glimpse into the daily life of case managers through a diary kept by one case manager employed in a Medicaid waiver program in California. Three decades and many system changes later, this article highlights care management within an Ohio elder services program funded, not by Medicaid, but by a local property tax levy and administered by the regional Area Agency on Aging (AAA). The care manager kept a diary for two weeks in June 2020.
On March 13, 2020, all in-person client visits were suspended and, due to the COVID-19 pandemic, program care managers were required to complete all interventions and contacts over the telephone. Levy program care managers had worked from home before the pandemic, stopping by the agency as needed to upload documents into client files, print necessary assessment and intervention forms, and shred documents that have been uploaded into the system. They now have an assigned two-hour window once a week for “office time” to perform these functions.
At the beginning of the pandemic, the AAA implemented a detailed Continuity of Operations Plan, which required all care managers to contact all of their clients and ask them specific questions, such as if they had enough food and supplies, back-up plans if levy services could not be provided, and to ask if they had any symptoms of the virus. In some cases, temporary home-delivered meals were initiated to reduce clients’ need to go to the grocery store and to help reduce possible exposure to COVID-19. If care managers were unable to reach clients by phone or mail, they were required to contact the sheriff’s department to request a wellness check.
The care manager knows several long-term program participants well. For individuals that started service during the pandemic, and with whom she has only had telephone contact, she does not have this advantage. These excerpts from one day of her diary provide not only a glimpse into her daily work life, but also of the unique challenges of providing community-based care management in the middle of the global pandemic when home-care staffing is significantly strained and agencies and businesses are closed or operating under reduced hours.
On the day of this diary entry, the care manager was serving a caseload of 124 clients. Participants in the locally funded program can have moderate levels of disability compared to HCBS waiver enrollees, who must meet nursing-home level care criteria.
8:00 a.m.–9:00 a.m. Reviewed emails. Copied on one email showing my supervisor had forwarded a temporary care plan cost cap increase request to my manager for approval. No voicemails on cell phone. Reviewed Documentation System (DS) for any case notes from providers on my Dashboard. Reviewed two referrals sent for a home-care aide (HCA) service and none of our contracted providers accepted. (Agency uses an electronic referral system to identify potential providers.) Sent an email to supervisor asking program to consider creating “unable to find HCA/provider” as a risk in DS, so care managers can easily pull up list of any clients for which we have not been able to find a provider. Currently, we have to track on our own on paper or in Excel.
9:01 a.m.–9:30 a.m. Prepared paperwork for an annual reassessment call scheduled for today at 2:00 p.m. with Client I (age 86) and her daughter. This would normally be a home visit, but due to the virus we are completing all visits over the telephone. I am still preparing my paperwork similar to what I would do if I were doing a home visit. Administration has reduced [the information] we have to gather for these calls, such as not having to complete a full assessment. On my visit cheat sheet, I go ahead and record Client I’s contact information, primary care physician (PCP), diagnosis, and that she receives Emergency Monitoring Response System (EMRS) as her only service. I also record her answers for her ADLs/IADLs from her last assessment.
I now have some additional new questions I am to ask: Does she want to help with our tax-levy renewal in some way? (Our levy is up for voter renewal this year and some clients place signs in their yards to encourage the community to vote “Yes.”) Does she have COVID-19 symptoms? Does she have enough food and supplies, and if not, who can help her get them? Does she have support to help her as a backup if the levy program could not help? Is she dealing with any anxiety, depression, or suicidal thoughts at this time? [Because] we are now several months into this pandemic, more clients are dealing with anxiety and depression.
‘Telephone call to Client II (age 72) who is being evicted out of his home due to a foreclosure and his house has been auctioned.’
At this time due to the pandemic, we are entering income and medical expenses verbally reported (normally this has to be visually verified), renewing care plan and service authorizations for the year, ADLs/IADLs are updated to ensure eligibility, and we enter a case note. If a client receives ongoing home-delivered meals, then we complete the nutrition risk and Excel eligibility tool. We are mailing annual renewal forms with return envelopes, these include release of information, receipt/offer of AAA’s HIPPA policy/rights and responsibilities, income attestation form, and client agreement if there was a change in copay. We have to track mailing, follow-up, and return of these forms in an Excel sheet.
9:31 a.m.–10:23 a.m. Telephone call to Client II (age 72) who is being evicted out of his home due to a foreclosure and his house has been auctioned. He has not received any notice that he has to vacate his home per his report. Had Independent Living Assistant (ILA) (ILAs visit clients every month as their advocate for benefits and programs that help them to stay in their homes and stretch their monthly incomes) set up for client to help him look for housing, but he could not afford his copayment and was not letting the ILA look for housing, anyway. She was helping with picking up prescriptions and ongoing utility issues. He wanted to “wait it out.” Informed him that the Sheriff’s Department is following through with evictions again (later found out this didn’t apply to foreclosures). Sent an email to Adult Protective Services (APS.) Documented contacts in case notes.
10:24 a.m.–10:46 a.m. Voicemail to Client III’s (age 82) daughter asking for a return call. I had received notice the client was in a nursing facility (NF) for rehab and placed home-delivered meals on hold. Tried significant other again who reports Client III fell and has a badly broken leg. Client is in local NF for rehab. They are hoping he is home by Father’s Day, but she is not sure if she will be able to provide the level of care he will need at home. Documented suspension follow-up in case notes.
10:47 a.m.–11:11 a.m. Email from manager/supervisor reporting over cost cap was approved. Authorized sixteen units (eight round trips) of medical transportation a month for Client IV (age 77) to go to outpatient physical therapy two times a week. Called client to advise of provider’s phone number and process. Explained [the transportation was] only authorized for two months, but if needed for longer client should inform me so request can be reevaluated. Documented authorization and phone contact in case notes.
11:12 a.m.–11:38 a.m. Email from home-delivered meals provider reporting Client V (age 92) has been in program since 2006. She fell and fractured her hip and is in the hospital and probably going to rehab). Went into each service in the DS and placed it on hold. Left a voicemail [with] client’s daughter informing her that I put client’s HCA, ILA, and home-delivered meals on hold. Documented four case notes—one from provider, one for voicemail to daughter, one documenting start of suspension, and email to HCA and ILA providers informing them of client being in the hospital and on hold. HCA provider informed me right away that HCA was just there yesterday. Updated status to “suspended,” and added to my suspended services tracking log that I’m using to record contacts within every thirty days, per policy. DS will notify providers of suspensions, but the timing of this is not clear, so I send providers an email, as needed.
11:39 a.m.–11:53 a.m. Checked HCA referral I sent for Client VI (age 70) and provider did not accept. I had received a call from an HCA and Client VI. Her friend is an HCA for one of our contracted providers. This is not our normal process, so I had consulted with supervisor after call. Re-sent referral to provider and also sent a separate email to provider asking them to consider the referral if they deem it appropriate that client’s HCA would be a “friend” of the client.
11:54 a.m.–12:18 p.m. Initiated a referral for Client VII (age 79) for HCA again. This will be my eighth attempt at finding an HCA provider for a client whose consumer-directed care worker is retiring. Noted that referral was initiated again in case notes. Received an email from provider for Client VI. They are going to check with HCA to see if she can really provide service for client. Email to provider explaining that I need them to accept, if possible, and then I will authorize (Email from provider sounded like I had already authorized and they could just start intake process). I still need to verify that client is willing to pay her copay for the service once accepted. Noted email from and email to provider in case notes.
12:19 p.m.–1:15 p.m. Took a break.
1:16 p.m.–1:51 p.m. Reviewed two emails from provider regarding Client VI. Their aide can start services on Sunday. Telephone call to client to obtain permission for copay and to discuss other concerns regarding her anxiety with COVID-19, race riots, and basement flooding repairs. Client declined Uplift (a community behavioral health program for older adults also funded in part by the levy program). She has been able to take care of her basement issues and mold remediation is in process. Levy program does not help with either of these issues and neither do any of the agencies that I called for Client VI. Sent authorization for HCA and sent email to provider. Wrote case notes for two emails from provider, one email to provider, authorization, and phone call to client.
Important assessment information will have to wait until after the pandemic as client is hard of hearing.
1:52 p.m.–2:45 p.m. Finished getting ready for annual reassessment over telephone with Client I and daughter and completed intervention call with them.
2:46 p.m.–3:03 p.m. Received email from APS and read reply on Client II. County is still not doing evictions for foreclosures and APS supervisor asked for more details about the possibility of client being scammed. Will call client in the morning to discuss further. Wrote case note for email from APS.
3:04 p.m.–3:40 p.m. Looked at intervention list for the month to see where I am on those contacts. Called Client VIII (age 70) to schedule annual reassessment and she just wanted me to complete then. I already had paperwork ready go, so completed with client over the telephone. Client receives an EMRS only.
3:41 p.m.–3:53 p.m. Break to take a quick walk.
3:54 p.m.–4:11 p.m. Email from ILA provider on Client IX (age 71) reporting doctor appointments his ILA arranged for him to get lab work done and to see an eye doctor. She also arranged his Medicaid medical transportation. Client is very hard of hearing, has vision issues, and has limited ability to read or write, so she helps him with these tasks. He is due for his annual reassessment this month, but I am unable to complete it due to client being too hard of hearing over the telephone. We are unable to do home visit at this time due to pandemic. I was able to get his updated income from his rep payee and have already renewed his care plan and reauthorized his services for the next service year. Other information will have to wait until we are cleared to do home visits again. Saved provider email in DS and sent an email to provider thanking them for information. Received signed annual reassessment forms for client and these were uploaded
4:12 p.m.–4:20 p.m. Returned a voicemail to Client X (age 80). She had left a message for me asking for a return call while I was on the telephone earlier. Documented call in case notes and sent email to ILA supervisor asking what happened at her initial visit with Client X. I have not seen any case notes from provider about opening her ILA service. She is one of my more challenging clients.
4:21 p.m.–4:28 p.m. Entered annual reassessment income and medical expenses in profile for Client I.
4:29 p.m.–4:42 p.m. Call from a client’s son who just turned 60 in May. He was asking what services he might qualify for himself through levy program. I explained that between ages 60 and 65 he would only be eligible for home-delivered meals if he meets the other eligibility criteria. He was not interested in home-delivered meals. Also discussed transportation through Title III and that he would need to call provider directly to schedule and ask for a NAPIS [National Aging Program Information Systems] form to complete. He needs transportation. He has not been able to get his ID renewed due to not having a birth certificate. Offices are also closed due to pandemic. He said his mom has the phone number to provider. Explained I had left a brochure for him at my last visit. The home-delivered meals provider had expressed concerns to me that client’s son was eating client’s home-delivered meals. Client had denied this when I delivered some food pantry items to client. At the time, I had also updated APS about ongoing concerns with client. They did not open a case.
4:43 p.m.–5:00 p.m. Worked some more on Client I’s annual reassessment documentation. Renewed care plan for the year and service authorization for EMRS.
5:00 p.m. Clocked out for the day. Tomorrow, I’ll need to complete the documentation from annual reassessment calls for Client I and Client VIII.