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, and 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, despite his sons thinking that he would not like them, and 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 memory care 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.