Recent Care Management Interventions:
A son living in Florida and whose parents live in Plymouth, MI has been concerned about their ability to remain living at home safely. In recent phone calls with his mother she complained that she had missed paying several utility bills and was being charged late fees. He also remembered that they forgot to pay their property taxes last year. Checking with the next door neighbor she reported there were days that went by when the snow was not removed from the walks and drive at his parent's home.
His mother also told him she was feeling very tired and depressed and felt like giving up. He Googled Senior Care Services, Wayne County, MI and found Michigan Geriatric Care Management Services and contacted me. I agreed to visit his parents and conduct a comprehensive evaluation to determine what kind of problems his parents might be having.
The initial evaluation revealed that both his parents were having short term memory problems and and that his father was having symptoms of Alzheimer's Disease. His father was a W.W.II veteran and often spoke as if he were living through the war again. Their ability to manage their basic affairs, like paying their bills, going shopping, and cleaning the house was getting worse.
His father had fallen and though not seriously hurt was afraid to shovel snow anymore. His parents also stated that they had not been able to get their medications refilled and had not seen their doctor in three months because they stopped driving. They did not tell anyone about these problems because they were afraid they might have to move to a nursing home. As a result of this initial evaluation I recommended the following treatment plan:
- A visiting doctor to come to their home to evaluate their current health problems.
- A home health care company to send a nurse to monitor their medications/heart rate/ blood pressure, a physical therapist to improve strength and walking, a home health aid for bathing assistance, and a social worker to advocate and link to community services to help maintain them at home.
- A neuro-psych exam to determine cause of memory and depression symptoms and treat appropriately.
- Referral for meals on wheels and liquid nutrition
- A comprehensive evaluation of any assets that were available to help pay for their care needs
- Referral to private duty care and chore services for respite care, and home and yard work
- Referral to legal aid to review need for guardianship since no power of attorney had ever been tablished and to review their will and Quit Claim deed for their home
- Referral for possible VA benefits
The parents and the son agreed with my recommendations and the plan was implemented. A visiting doctor came and ordered home health care services based on their medical problems and needs. These medical services are paid for by Medicare. Since I function as a medical social worker and consultant for home care companies I was assigned to be their social worker from the home care company ordered by the doctor and have been able to help them. The case is ongoing and we will update this case study as this case progresses.