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Cluster Care: A Care Solution for Independent Living

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Cluster Care: A Care Solution for Independent Living

By Larissa Pourron, RN

Cluster care is provided in independent living communities for clients who need a little extra help.  Most clients are independent, however they still need some assistance with tasks such as medication reminders or getting dressed.  The client is at the center of each and every visit.  Each visit and task vary depending on the individual needs of the client.  

Personal and Companion Care

The needs can range from companion care to personal care.  

Companion care services include monitoring for safety, light housekeeping, meal preparation, laundry, transportation, and medication reminders.  

Personal care services include assistance with bathing, dressing, grooming, transfers, walking and toileting and all companion care services.  

How long are the care visits?

A cluster care visit can last from 15 minutes to one hour, the length of which can vary depending on the day.  Some clients need 15 minutes a day, seven days a week for medication reminders, while other clients only need care two days a week to receive help for a shower.  

How do I begin services?

To start cluster care services, an assessment needs to be done by a registered nurse.  This assessment is a gathering of information about the client, including a health history and their current living situation.  This assessment along with the family’s knowledge allow us to determine the needs of the client.  

Our biggest challenge often convincing the client that they need the help.  Most clients have taken care of themselves and others so long that they see no need for assistance.  It’s hard for a parent of any age to hear their child tell them what they need to do.  

What happens once a care plan is in place?

Once the client agrees to our services and a plan of care is made to center around the client’s needs, the caregiver is able to see them.  Our caregivers are able to assist these clients with their daily needs.  The caregivers are wonderful.  They are the eyes and ears for me as the nurse.  They keep me informed about clients so that I can keep the family involved.  

Am I, as a family member, involved in the process?

Cluster care does not work without family involvement and constant communication.  We let families know what is going on with the client but we also notice and report the new things. A client we walk to the dining room regularly, for example, is never short of breath but today he is or the client whose weight is up two pounds from the day before.  We give that information to the family so they can inform the client’s doctor.  We are also able to let the family know when the client may need additional services.  As the clients change, we adapt to their needs with the help of them and their family. We work closely with home health and therapy to make sure the client has all the services they need. 

For example, I had a client who was having frequent falls.  I told the client’s family member and told them about the physical therapy services offered in that independent living community.  The client was able to get therapy in conjunction with our services and hasn’t fallen since.  

How is Cluster Care properly done?

1. The Cluster care can only be successful with a great relationship with the community resident managers. We recognized this from day one and we’ve been fortunate to develop deep relationships with key community personnel.  We’ve earned this over time and the trust in us is evident and appreciated.

2. Establish a dedicated Community Care Coordinator Position. We found it’s essential to have a dedicated community care coordinator on-site.  Over time, our care coordinator gets to know the community and the families inside and out.  They become part of the community.  They are responsible for the overall care satisfaction in the community and the supervision of caregivers on site. They work closely with on-site physical and occupational services as well.

3. Establish a dedicated Registered Nurse (that’s me). I work closely with our care coordinator and I’m responsible for performing personal care assessments and care plans for the residents at the community.  Understanding the medical well-being of our clients is very important to help our clients thrive in the community.  Besides being the RN, I'm the right hand to the care coordinator for advice and support. I also work closely with on-site Home Health services and brief the resident managers if I have any concerns and/or recommendations.

4. Have the right tools. Open lines of communication are necessary between the home care company and the client, family, facility, and other health care providers.  Cluster care allows a client to stay in their current facility with short visits to take care of the little things that might otherwise grow into larger problems.  Besides face-to-face meetings with resident managers, clients and their families and Home Health, we use technology as an advantage to communicate with families electronically.  Our caregivers use mobile iPads to understand their schedule and “sign off” tasks as they are done in real time.  Clients also can sign the visit task sheets electronically a feature they really like.  Families like this feature to track care is being performed when asked for and in some cases this same data is used for long term care insurance submission.

In closing, what we learned is home care in independent living communities is a VERY different care model than in-home care.  The caregivers assigned to cluster care have a special skill set for caring in a community which requires a good grasp of technology. They thrive in multi-tasking and most importantly, they have a great caring heart.  To manage this care, we need tools to be able to schedule multiple clients with very short visits, which is not the case in a traditional home care environment.  Lastly, we need to staff a team with a solid leader that is in essence part of the community.

For more information about cluster care, feel free to give us a call about the services we provide at (919) 436-1871.