Most families begin the work of coordinating care for an aging parent after a precipitating event. Usually it's a fall, a hospital discharge, or a doctor's offhand comment about "not driving anymore." I've sat with hundreds of adult children in that first panicked week, and the advice is usually the same. Begin with paperwork. Begin with conversations. Do both before there's a crisis to react to.
Here's how I walk families through it.
1. Gather a single "face sheet"
A face sheet is the one-page summary an EMT, ER nurse, or new primary-care provider needs in the first ninety seconds of meeting your parent. At minimum it includes: full legal name, date of birth, address, emergency contacts in priority order, primary-care physician, relevant specialists, pharmacy, insurance, current medications, known allergies, and major diagnoses. Keep it current.
In our practice we update face sheets every 90 days and after every hospital event. If you're using Agensy, the talking-forms feature keeps this up to date automatically once you enter the underlying facts. If you're working from paper, a binder and a monthly reminder on your phone will do the job.
2. Identify the four decision-maker questions
These are the questions that determine who speaks for your parent when they can't. Ask them while your parent is well, not after a stroke:
- Medical Power of Attorney. Who makes medical decisions if you cannot?
- Durable Power of Attorney (financial). Who manages bills and finances if you cannot?
- Living will / advance directive. What do you want in the event of severe irreversible illness?
- HIPAA release. Which family members are permitted to speak with your doctors?
Each of these is a specific legal document. Have them drafted, signed, and stored somewhere other family members can reach, not just the family attorney's office where it may take 48 hours to retrieve.
3. Map the care circle and what each person is allowed to see
A care circle is not a group text. It's a deliberate list: who has access to what. In the typical family caring for one parent, the circle looks like this:
- Two adult children with full medical visibility.
- One caregiver with access to the daily schedule and care-plan updates, with no financial access.
- The primary care physician and one or two specialists with read-only access to relevant medications and recent appointments.
- A neighbor or long-time friend with emergency-only read access.
When everyone knows their role, you avoid the two most common failure modes: siblings duplicating each other's calls, or important information living in one person's text thread.
4. Run a structured hospitalization checklist on day one
Hospitalizations are where most care coordination breaks down, and where a prepared family can make a measurable difference in outcomes. At admission, you need: the face sheet (again), the current medication list (not the one from last year's checkup, the one from this morning), a list of allergies, and the care directives document. Hand these to the admitting nurse as a packet. Ask for a copy of the admission summary; ask again before discharge.
At discharge, confirm three things on paper: (1) the reconciled medication list: every new med, every changed dose, every stopped med, and what it replaces; (2) scheduled follow-up appointments with names and dates, not vague "see your PCP in a week" instructions; (3) red-flag symptoms that require a call back to the hospital rather than another visit to the PCP. I ship families our hospitalization checklist for exactly this.
5. Decide your posture: reactive vs. proactive
Reactive coordination is the norm: families respond to each medical event as it happens. It is exhausting, expensive, and measurably worse for outcomes. Proactive coordination means meeting quarterly as a family to review the care plan, even when nothing is changing. It means the face sheet and medication list are always current, not just current right after a hospital stay. Proactive coordination is the work professional care managers are hired to do. With the right tools, a family can do a credible version of it themselves.
What professional care managers do differently
Experienced ALCA members typically juggle 50–100 active clients at any given time, and the most seasoned practitioners carry 80 or more. We work the checklist above on every one, all the time. The paperwork is never out of date because we've built workflows that force it to stay current. Agensy exists to put a version of those workflows in the hands of families who can't afford to hire a care manager, or who can afford one but want to learn the work themselves. Either way, the work is the same. The difference is the tooling.
If you are a care manager looking at the professional tooling, start here →
If you're a family member new to this, see how Agensy is organized →