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Martha’s Move

Client: Martha

Situation: She was in the hospital and needed to find a place to live after discharge. She knew she couldn’t go back to her home because of her health situation.

Challenges: Her family was involved but not helpful, so she had nobody to advocate for assist her. She had limited financial resources and needed some rehabilitation time. Her paranoia, hoarding tendencies, and poor record keeping presented a challenge in living options.

Care Manager’s Process: First, listening to her and hearing what she was saying was the most important step. I gathered information from her and assessed her needs and abilities. This helped me create a plan of action. Since the client didn’t want her family involved and she was able to make decisions, my work was to help her make those care decisions and find a living option she could call home.

I recognized that Martha needed to have rehabilitation time so I convinced her to go to a nursing home upon release from the hospital to get the rehab that she needed. While she was in the nursing home, I helped her start the process to apply for Medical Assistance.

Because of poor record keeping this challenge required working closely with Martha to gather verification of life insurance policies, pensions, assets, and expenditures. I worked closely with the County on this process and it required significantly more time and assistance than the County could provide. I dedicated my time to following through on this process.

After Medical Assistance was approved I helped Martha find an Assisted Living environment that would provide her with maximum safety and independence, while meeting her personal, financial and supervision needs.

Outcomes: With this advocacy, organization, knowledge of resources, and assistance, Martha was able to trust somebody more than she had previously trusted anyone. I advocated for her needs in a way that found her the best living situation that she was able to call “home.”

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Keeping Jerry at Home

Client: Jerry

Situation: Jerry was a widower who’d had a strained relationship with his sons. Neighbors, family and police were noticing strange and inappropriate behavior at times. The police were involved when he had a “minor fender-bender.” This led to the County Social Services becoming involved due to concern about Jerry’s mental capacity and ability to drive and function safely in his home.

Challenges: Find a way to care for Jerry in a way he would be receptive to. Create opportunities for medical treatment and social interactions. Jerry lacked inhibition and had impaired reasoning and thought processes. At the initial meeting it was apparent that Jerry had some level of dementia. The frustration of the sons’ attempts at communication was obvious. Jerry also had not been to a doctor in over 25 years.

Care Manager’s Process: I arranged for Jerry to see a physician who specialized in geriatric medicine and helped him get a complete physical and neurological exam. He was diagnosed with frontal-temporal dementia and a B-12 vitamin deficiency. I developed an ongoing plan of care for him with monthly visits to the doctor for B12 injections I would take him to the doctor’s visits, as he would not allow his sons to assist him.

I worked to coach his sons and the caregivers , on how to communicate with him and avoid arguing or trying to reason with him. We also created a written schedule for Jerry to follow, as this helped him to stay focused on daily needs and a routine.

It was apparent by the lack of food in his fridge and his reports of “eating at the gas station” that Jerry was not eating healthy meals. I coordinated Meals on Wheels and his sons thinking that he would not like them, he loved it. I was thus able to make sure he was receiving daily meals, and his energy increased simply due to better nutrition. With that food came a brief interaction with the delivery person, at which he looked forward to that social contact.

Though he appeared neat, I could tell that he had not actually bathed in quite some time. I coordinated and worked with a home care agency to have a caregiver see Jerry a few times per week to remind and encourage him to shower, put on clean clothes, and brush his teeth. She was also able to take him out since he was no longer driving. He wanted to attend Mass so I was able to request a caregiver from the home care agency who would attend Mass with him. The caregiver was also able to do housecleaning, laundry, and meal preparation for Jerry. I closely maintained oversight of the work being done by the home care agency and increased their visits as it became evident that Jerry needed more in-home assistance.

Eventually, Jerry’s dementia progressed and he needed additional physical and nursing care so I worked with his sons to find the best residential care option for him in a skilled nursing facility dementia unit.

Outcomes: My on-going care management allowed Jerry to stay in his home for almost two years longer than he otherwise might have, and to have excellent care at the end of his life. Throughout that time I was the advocate, liaison, and care coordinator between him and his family, the Home Care agency, the county social services, and his medical team. I’m honored to have provided Jerry and his family with this support, guidance, and care.

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Marie and John: The Young Couple

Client: Bob

Situation: Bob is Marie’s father who lives alone in his own home and has early dementia. Because Marie and her husband John live the closest, they’ve become his primary caregivers.

Challenges: They‘re feeling the stress of handling their jobs, home, family and social life, and they’re worried about Bob’s safety, personal care, finances, and household management There is additional family and friends available to help but Marie and John are not getting the family support they need and desire. A structured plan for care is missing and having one would make it easier to manage all of Bob’s care without overlooking anything important and placing the caregiver burden solely on them.

Care Manager’s Process: I met with Bob at his home and did an assessment with Marie and John present. We discussed the big picture and Bob’s strengths and deficits of the current situation. An assessment was completed of Bob’s self-care abilities, as well as home safety and fall risk. From this visit I was able to determine his needs, abilities, potential safety risks, general health status, financial status, and emergency preparedness. With this information, I was able to create a thorough plan of care. I met with other family members and we discussed Bob’s needs and created a structured schedule of what needs to be done, when, and by whom. We learned there was even a family friend who was willing to help with care.

Outcomes: With my assistance we were able to consider each family member’s input to work together to create workable solutions for Dad and his well-being. This led to improved family communication and a commitment to Bob instead of the previous situation where everyone was looking out for themselves. Bob is now receiving the daily assistance he needs and that burden of care is more evenly dispersed among more people, alleviating the stress on Marie and John. The result of this is that Bob also gets to spend more time more family that he loves.

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