Client History

Norman has successfully lived alone for four years following the death of his wife.  Norman’s daughter, Gina, lives 90 minutes from Norman, visits him once per week and accompanies him to his medical appointments.  Gina has observed a steady decline in his health over the past six months.  She noted that Norman has not been as active in the community and his housekeeping is not up to Norman’s usual standards.

 

Process

  • We met with Norman and Gina for an in-person interview and to discuss the duties of a care manager.
  • We discussed Gina’s observations of Norman’s decline privately. Gina indicated she is just not able to provide the care that Norman requires due to her family and work demands. She confided she feels as if she is neglecting Norman but she does not have enough medical background to understand his needs.
  • Norman signed a consent form to allow us to request his medical records to complete a thorough file review and establish the medical treatment he is receiving for his diabetes and other conditions.
  • We evaluated his home for safety and needed modifications. His is very unsteady at times and struggles to get up and down the steps. We documented the need for grab bars in the bathroom and a stair lift.
  • The care manager attended medical visits with Norman’s PCP and endocrinologist. We obtained an accurate medical history, list of all medications, and information on Norman’s current and future medical needs during these visits.

Analysis

Upon completion of the medical record review and attendance at the appointments noted above, the case manager was able to meet with Gina and Norman to discuss recommendations for monitoring Norman’s medical status on a more regular schedule. We agreed to speak with the Norman’s physicians on a regular basis and attend appointments every 60 days. We identified concerns related to Norman’s safety and agreed to maintain weekly contact with Norman and his caregivers and meet with the team monthly. We also established a plan for monitoring medications and overall health.

 

Outcome

The care manager was able to work with Norman’s providers to establish a plan for monitoring his safety while alone in his home.  A visiting nurse was hired to visit with Norman once per week to check his blood sugar levels and administer medications as needed. Aides were hired to assist him 2 hours per day. We located senior activities for Norman to attend and identified an affordable transportation option.  We worked with Gina to establish a plan of care for Norman’s future needs. We helped to connect Gina with resources to assist with payment for future medical needs should his health decline further. We assisted Gina in working with a financial planner to establish a trust for Norman’s money to pay for his future care, which are not covered by the senior service resources we identified.