Helping older adults and their families determine, coordinate, and manage care needs.

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 her and assiste her. She had limited financial resources and needed some rehabilitation time. Her paranoia, hoarding tendencies, and poor record keeping presented a challenge in potential 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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