Training › For Family Advocates › Coordinating care
ADVOCATE ยท ADVANCED PRACTICE
Working with Multidisciplinary Teams and External Agencies
Sylvie's discharge planner calls on a Friday afternoon. The hospital is sending Mrs Diallo home on Monday and the home care assessment will be delayed three weeks. Your job for the next ninety seconds is to hold the connective tissue while everyone else does their own job.
This module is for advocates carrying a Delegated Authority case. By the time a family reaches Delegated Authority, they are usually working with three or four teams outside iCaria already: a primary care doctor, a community health nurse, a hospital discharge planner, a social worker, the housing office, a religious or cultural organization, sometimes a lawyer. None of those teams are in the iCaria portal. None of them have read the others' notes. Your job is to be the person who has.
You are the family's coordinator. You do not prescribe care; you coordinate it, communicate it, and stay with the family. The clinical authority is theirs. The legal authority is theirs. The coordination authority is yours. This module is about the boundary, the introductory call, what you share, what you hold, and when to step back without stepping out.
Map the teams in the family's life
Before any phone call, sketch the map. One page, by hand, is fine. The point is not the diagram. The point is that you can read it back to a new iCaria provider in under a minute when they arrive on Monday morning.
For Mrs Diallo, the map might read like this. Primary care: Dr Lee at the clinic on Sheppard. Hospital: the discharge planner you are about to call. Community: the day program at the Scarborough community center her daughter Karim brings her to twice a week. Housing: the building manager who fitted the grab bars last year. Religious: the priest at Saint Margaret's who visits on Sundays. Family: her daughter Karim, who lives ten minutes away, and her son who calls from Calgary on weekends.
For each team, three things. Who is the named person you have on the phone. What that team is responsible for. What the family has agreed they may share with you.
The map is for the iCaria providers, not for the outside teams. The hospital does not need your map. Your helper arriving Monday morning to support Mrs Diallo's first day home does. Leave the map in the family's care plan in the advocate portal. The Monday morning helper reads two sentences and walks in with the whole picture.
The introductory call
You will make this call dozens of times across a career. Get a clean shape on it and the call takes three minutes. Get a muddled shape on it and the call takes twenty minutes, the discharge planner remembers you as the advocate who talks a lot, and the family is no further ahead.
Four things in order. Who you are. Why you are calling. What you can offer. What you are asking for.
Who you are
- "My name is Karim. I am the iCaria advocate for the Diallo family." That is enough. You do not explain what an advocate is on this call unless they ask.
- If they ask, one sentence. "I am the family's coordinator. I am not clinical. I stay with the family across all the teams in their life."
Why you are calling
- One sentence. "I understand Mrs Diallo is being discharged on Monday. I am calling so the home support is in place when she arrives."
- You do not narrate the family's whole story. The discharge planner is on a tight clock.
What you can offer
- One or two sentences on what iCaria providers will be doing. "Our helper will be there Monday afternoon and three more times that week. Transport to her Wednesday follow-up is arranged."
- This tells the discharge planner that you are real. It also tells them what they do not need to arrange.
What you are asking for
- Be specific. "I am asking for the discharge summary by end of day Friday, and the name of the community health nurse who will be assigned. The family has agreed I may receive both."
- If you do not have family consent to receive a document, say so and ask the team how to get it. Do not pretend.
End the call by reading back the next step in one line. "I will email you the consent form by four o'clock. You will send the discharge summary on Friday. We will both look out for the nurse's name." A good call ends with both people knowing what happens next.
What you share, what you hold
The family's consent governs what you share with an outside team, not the outside team's request. This is the place advocates most often slip. The discharge planner asks a reasonable question. You know the answer. You share it. The family did not agree to that piece being shared with the hospital.
Hold the line on two simple rules. First, the family told you what you may share with each team when you built the map. Second, if a team asks for something the family did not agree to share, you say so plainly and ask the family before the next call. "I do not have consent to share that piece. I will check with the family this evening and come back to you tomorrow."
The reverse direction matters too. When an outside team gives you information, ask yourself who in the family has heard it. If Sylvie's primary care doctor tells you her cognition has been declining and her daughter has not been told, your job is not to keep that quiet inside iCaria's walls. Your job is to hold a careful conversation with the doctor about how the family should hear it, and to make sure the older adult is not the only person in the room who has heard the whole story.
The boundary in three sentences
- You share what the family agreed you may share. No more.
- You ask the family for new consent when a team asks for something new. You do not improvise.
- You do not hold a clinical fact from the family because the doctor mentioned it to you in passing. You broker the conversation that gets the family informed.
You are not the clinical authority. The advocate's authority is coordination. When a discharge plan, a power of attorney activation, or a safeguarding investigation is in motion, the clinical or legal team's authority overrides yours on that specific decision. You do not push back. You do not negotiate the clinical call. You record what happened, you communicate it to the family in their language, and you re-plan the coordination around the new reality. Stepping back from a clinical decision is not stepping out of the case.
When to step back, and how to step back without stepping out
Three situations call for a step back. A discharge plan is set by the hospital. A power of attorney is activated. A safeguarding investigation is opened by a regulator or by iCaria safeguarding. In each of these, the authority on that decision has moved to someone else.
Stepping back means three things. You stop trying to influence that specific decision. You make sure the family understands what is happening and what their rights are. You stay in the coordination role for everything that is not that specific decision.
The case that goes badly is the one where the advocate keeps trying to override the hospital's discharge plan because the advocate knows the family better. The family does not benefit. The hospital is forced to defend a decision that is theirs to make. iCaria is positioned as adversarial to the clinical team. Coordination breaks.
The case that goes well is the one where the advocate accepts the discharge plan as the discharge plan, helps the family understand it in their language, asks careful questions about what support the family needs to make it work, and then re-plans the iCaria coordination around it. Same situation. Different shape.
Keep the elder in the room
The most common failure on a Delegated Authority case is not a clinical one. It is the moment the older adult realizes everyone else has been talking about them and they are the last to know. The discharge planner, the daughter, the community health nurse, the advocate, the helper. Five people who have all spoken about Mrs Diallo's Monday morning. One person, Mrs Diallo, who has not been told.
Every cross-team conversation has a small final step. Write down what was decided in two sentences. Bring those two sentences to the older adult in their language. Ask whether the plan sounds right to them. If they want to change something, change it. If they want to ask the doctor a question you had not thought to ask, that question goes on the next call.
This is the piece outside teams cannot do. Hospitals discharge dozens of people a week. Community health nurses see a list every morning. Social workers carry a caseload. The advocate is the only person in the system whose job is to make sure the older adult is not the last to know.
Key takeaways
- Map the outside teams in the family's life on one page. Named person, what they are responsible for, what the family has agreed you may share with them. The map is for the iCaria providers walking in on Monday, not for the outside teams.
- Make a clean introductory call in four parts: who you are, why you are calling, what you can offer, what you are asking for. End the call by reading back the next step in one line.
- The family's consent governs what you share. When a team asks for something new, ask the family before the next call. Do not improvise.
- When a discharge plan, a power of attorney, or a safeguarding investigation is in motion, the clinical or legal authority overrides your coordination role on that decision. Step back without stepping out. The coordination role does not end when a clinical role begins.
- After every cross-team conversation, bring two sentences back to the older adult in their language. The advocate is the only person in the system whose job is to make sure the older adult is not the last to know.
Finding this again Open Training from your portal any time to come back to this module. A knowledge quiz follows. You pass it once before activating your caseload, and again each year when you renew your certification. This is an Advanced Practice module, applying to advocates who work at Delegated Authority. It pairs one reading lesson with a short video and an eight-question knowledge check.