Customized Plans to Enhance Everyday Independence

Customized Plans to Enhance Everyday Independence

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Dennis Gill: Hello, listeners. Welcome to CareSmartz360 On Air, a Home Care Podcast. I’m Dennis Gill, Senior Sales Consultant at Caresmartz.

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Dennis Gill: Today, we explore the design behind personalized support and independence at home.

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Dennis Gill: So, I’m thrilled to welcome Melissa DeSutter from Right at Home of Northwest Indiana.

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Dennis Gill: Melissa’s passionate about creating customizable care plans.

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Dennis Gill: From meal prep and medication reminders to hands-on help.

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Dennis Gill: So, with empathy and with expertise. Stick around to discover how tailored home care can truly empower everyday independence through compassion and collaboration.

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Dennis Gill: So, Welcome to the podcast, Melissa.

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Melissa DeSutter: Thank you, Dennis, thanks for having me.

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Dennis Gill: No, we’re really glad you were able to take out the time today for our listeners, and I hope this session is pretty fruitful for our listeners, too, and you have a great time today in having an interaction with us, and same we have with you, too.

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Dennis Gill: Alright, so I’ll straight away jump in with my first question for you.

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Dennis Gill: So, Melissa, how do you begin crafting a truly personalized care plan, from the first conversation to tailoring services around each client’s daily routine?

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Melissa DeSutter: Sure, so that’s a great question. So, when we are trying to build a customized care plan, the first thing that we’re trying to do is learn what is the goal of care.

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Melissa DeSutter: And then we’re also trying to understand what led to the reason that the family or potential client was making the call.

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Melissa DeSutter: So, the way that we start is by asking a lot of questions.

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Melissa DeSutter: Trying to learn where… where are the care gaps, where are the needs, where is the family or, support network?

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Melissa DeSutter: Needing additional help.

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Dennis Gill: Okay.

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Melissa DeSutter: So we’re trying to ask a lot of questions, so some of those questions may include, okay, what made you make this call today? What’s happening in the home? What are changes that you’re seeing with your loved one?

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Melissa DeSutter: And so, a lot of times, our families experience something that led to the reason that they’re looking for home care services. So, it could have been a loved one who had a fall, and as you know, falls are quite common with the senior population.

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Melissa DeSutter: Okay. And so, maybe that individual then fell, was hospitalized, experienced some time in a rehabilitation environment, and now they’re getting ready to go home. But they’re not quite exactly at the same level of functionality as they once were.

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Melissa DeSutter: Prior to that accident. We also have clients that may start to, exhibit different signs of dementia.

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Dennis Gill: Memory care loss?

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Melissa DeSutter: And so, families are concerned for their safety.

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Melissa DeSutter: And they’re looking for support because, maybe their spouse or parent can’t be left alone anymore. And so they’re trying to decide, what does this look like? And part of our job, when we’re having that first conversation with the family, is to really dig in and learn

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Melissa DeSutter: you know, what is going on there, who is part of the care? You know, what are the barriers, where are the gaps, and how can our caregiver team come in there and provide that level of support, not only for the client, but also as support and a break for that family unit.

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Dennis Gill: Okay, okay. And in what ways do you ensure that care plans evolve as clients’ needs shift, especially as they become more mobile or require different types of support?

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Melissa DeSutter: Absolutely. So, the way that we kind of ensure that the care plan is, like, a fluid plan that’s always changing, the way that we do that is, initially, when we meet with families and get services started, we build that initial care plan.

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Melissa DeSutter: And so the initial care plan kind of serves as a baseline in terms of, you know, this is what we know client Mr. Smith to be right now, real time, and then we can kind of measure against that, or, you know, compare as things shift with that particular individual. The way that we are monitoring and seeing

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Melissa DeSutter: what’s happening in terms of changes in conditions. There’s lots of different ways that we’re doing that.

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Melissa DeSutter: So, one is when we are bringing on new clients, we have our client care coordination team that’s highly involved.

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Melissa DeSutter: Okay. So, we are making sure that we are doing a home safety eval. We do not send caregivers into environments that our careg… our care coordination team has not stepped in themselves to see, you know, what is going on in the home.

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Melissa DeSutter: And let’s say, for example, someone is getting ready to discharge from the hospital, and, you know, they seem really

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Melissa DeSutter: pretty… they’re in pretty good shape mobility-wise, and they’re looking forward to going to the doctor. But then, as we get in there, we see that this individual

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Melissa DeSutter: no longer wants to go to a physician appointment. They do not want to continue taking their medications, or they’re, you know, feeling frustrated because they have to have another treatment of some sort. So, we’re looking for signals that the client is telling us, either directly or indirectly.

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Melissa DeSutter: Which may then trigger, hey, do we need to talk to them about bringing in home health services? Is this a client that potentially could benefit from having palliative care or hospice care? So we’re always looking to see what else can this individual benefit from.

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Melissa DeSutter: In addition to, you know, different service lines.

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Melissa DeSutter: We’re also looking at community resources, because some of our families, you know, they may really benefit from having, like, a meal service delivered to their home. So, is that something that now has changed, because maybe the spouse isn’t doing so well? So, we’re also looking to see what’s going on with the entire family unit.

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Melissa DeSutter: Not just that particular client. For example, if a spouse typically was able to drive their loved one to their doctor’s appointments, but then maybe they themselves had an injury, now we’re updating the care plan because transportation has to be included.

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Melissa DeSutter: Maybe they were once very independent with getting dressed, and now we’re seeing them struggle. So we’re gonna update the care plan there as well. I don’t know if that answers your question.

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Dennis Gill: Yeah, it does, definitely it does, because I completely understand, because as I told you, that for 6 years I’ve been working with the home care industry, specifically non-medical home care, because our.

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Melissa DeSutter: Yeah.

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Dennis Gill: also helps in that part, like customizable care plans we have in our system. So we… what we do is, in our system, we provide basic tasks, and it’s completely up to the agency. It can be completely customized. So, I understand, agencies, they do require it.

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Dennis Gill: I am completely aware of that step.

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Dennis Gill: Okay, so the next thing, what steps, do you take to involve families or clients themselves into the design process, especially when emotions or sensitive references come into play?

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Melissa DeSutter: Yes, that’s a great question, and…

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Melissa DeSutter: Many times, more times than not.

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Melissa DeSutter: all of this is highly sensitive, it’s highly emotional. I mean, even for a lot of families, I would even say it’s slightly traumatic to see loved ones change in such a way that they never once were before. So, we absolutely lean on family to be involved.

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Melissa DeSutter: We do have very candid conversations in terms of comfort levels. So, for example.

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Melissa DeSutter: somebody who, like, let’s just say a parent is aging, and now they need help with showering, you know, we’ve found that some family members or adult children have a comfort level, like, I can give my mom a shower, it’s not a big deal. Whereas, you know, another family may say.

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Melissa DeSutter: No, that is not something I ever want to do, not because they don’t love their loved one, but it’s just out of their comfort zone.

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Melissa DeSutter: And so, we really try to gauge

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Melissa DeSutter: You know, where the family is comfortable, where they are uncomfortable, and that helps us to also, you know, build out a care plan that kind of fits within that family structure.

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Melissa DeSutter: The other piece, too, is, a lot of families who call us

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Melissa DeSutter: They are creating their own sort of care plan environment without us even being there yet. So, for example, some families

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Melissa DeSutter: They’ll say, hey, you know, Monday, Tuesday, Wednesday, my brother’s here. On Saturdays and Sundays, it’s the neighbor, and then we need you to fill in the gaps. And so then they’ll hire our team to kind of fill in where there’s a missing piece.

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Dennis Gill: And so….

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Melissa DeSutter: We want to make sure they’re all doing the right… doing things the right and safe way, too, when we’re not there, so we leave, recommendations as well.

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Dennis Gill: Oh, okay, okay, got it.

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Dennis Gill: And, how do you equip caregivers with the training and resources needed to deliver not only tasks, but comfort, companionship, and specifically, adaptability to individual preferences?

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Melissa DeSutter: Right, so the caregiver is really the epicenter of everything we’re doing here. I mean, the caregiver is the business, and what I really love about our company here, and right at home, Northwest Indiana.

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Melissa DeSutter: Our owners are very passionate about making sure that we are hiring the right people who know how to do the right things. And so…

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Melissa DeSutter: There’s lots of ways that we ensure that we’re hiring, you know, the best folks for these positions.

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Melissa DeSutter: So that includes doing a multiple-choice exam, looking for critical thinking skills, so that’s one layer. Obviously, all of our folks have to pass background checks and whatnot.

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Melissa DeSutter: We also have a skills lab on-site.

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Melissa DeSutter: Okay. And what’s really nice about that is they can demonstrate that they know how to do and use different pieces of equipment. So, for example, if we have a client that’s struggling with, you know, transferring and walking, we’re going to want to send a caregiver there who has experience using a gait belt.

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Dennis Gill: Got it.

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Melissa DeSutter: And so, I tell people it’s similar to trying out for a sports team. Like, you have to demonstrate you know how to do the skill.

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Dennis Gill: What experience do you have in that, yeah?

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Melissa DeSutter: Exactly. Not just, hey, I’ve done this before, but you have to show us that you really, really know, you know, what you’re doing there, which is nice, too. Everybody also has to have at least one year of experience.

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Melissa DeSutter: One thing that’s great about Right at Home is that we offer a lot of different types of ongoing training for our caregivers. So they literally have access to so many different topics.

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Melissa DeSutter: Which we highly, highly encourage for them to take. Some of them are required, some of them are, you know, by choice, if they’d like as well.

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Melissa DeSutter: But that’s all weaved into how they’re matched with our, with our clients, too.

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Melissa DeSutter: So training’s a big, big deal. Specifically for our location, dementia.

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Melissa DeSutter: We want to make sure that any of our caregivers who are going out serving someone that has either a known or suspected dementia diagnosis, that they’re in good shape.

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Dennis Gill: Got your point, got your point.

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Dennis Gill: And, finally, what systems or communication methods do you use to monitor or adjust plants regularly to stay ahead of changing circumstances?

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Melissa DeSutter: Yeah, so, the system that we currently use, and this is through Right At Home, is called WellSky. Okay. So that, that’s a program that we use to help, you know, build our care plans.

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Melissa DeSutter: And also create multiple tags within a care plan. So, for example, if somebody’s on a particular service line, but also, like, what’s going on in the home. So, you know, there’s tags in case someone has

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Melissa DeSutter: A pet, or if they have certain allergies.

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Melissa DeSutter: And, what’s kind of nice about that system is that we can also create reminders to make sure that, you know, we’re following up.

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Melissa DeSutter: Sometimes we have clients that, unfortunately, for one reason or another, they’re going to the hospital, and so we are also updating

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Melissa DeSutter: that care plan within WellSky, …

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Melissa DeSutter: So that we’re not missing anything, because a lot of times there are those changes in condition.

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Dennis Gill: Okay?

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Melissa DeSutter: And also triggering in-person visits.

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Melissa DeSutter: To see, you know, what is going on, because, you know, we can’t take what, like, the families are saying always at face value. Sometimes they don’t see everything, or sometimes it’s just so emotional for them, they forget different pieces.

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Melissa DeSutter: So, you know, trust and verify as well.

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Dennis Gill: Got it, got it. So you’ve been using….

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Melissa DeSutter: Oh, good.

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Melissa DeSutter: Yeah, and it’s a good system, too, in terms of matching our caregivers with our clients.

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Dennis Gill: Okay?

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Melissa DeSutter: Because there’s all these different little tiny details. I mean, anything from, you know, Dennis wants care in the evenings. Alright, well, who are our evening caregivers? How are we plugging them in?

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Dennis Gill: Got it, got it.

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Melissa DeSutter: So that is, … that’s… that’s a super smooth way to just kind of ensure that things are… are moving smoothly and swiftly.

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Dennis Gill: Good to hear that. Yeah, because nowadays it is an operational system is a must for the agencies, because it does help everything you keep on tab, everything on the go. Owners are there, or even the scheduler is there, so they can always keep a track of it when they’re on the go.

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Dennis Gill: It really does.

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Melissa DeSutter: Yes.

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Dennis Gill: sad, yeah.

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Dennis Gill: Okay, okay, yeah. So, thank you for your expertise and your time today, Melissa, and it was really nice talking to you, and I hope it is beneficial for our listeners also, whatever we discussed today, and we hope to have more conversations with you in the future, and discuss more about the topics on home care industry then.

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Melissa DeSutter: Thank you, thanks so much for having me, it was nice to meet you.

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Dennis Gill: Thank you, Everyone. Thank you listeners. I’m Dennis Gill signing off today, so I’ll see you soon. Thank you. Ciao.