The Case Management program meets a variety of needs for seniors 60 years of age and older. Case managers serve as expert resources in evaluating the needs of the elderly, recommending services, and working with seniors in an ongoing relationship. Case managers begin by performing a comprehensive evaluation of the elderly person’s functional abilities. The evaluations take place in the home, or in the hospital prior to discharge. Seniors are evaluated for their abilities to perform everyday mental activities such as orientation to person, place, and time, and the ability to manage resources like income, home, and other material assets. Their functional strengths and deficits are assessed regarding their ability to move around in the home, prepare meals, perform daily activities of grooming and hygiene, complete tasks of routine housekeeping, and venture outside the home.
Once abilities have been determined, the case managers work in collaboration with seniors to construct a care plan. The care plan represents the best combination of services available to meet the needs of elderly clients. Needs typically vary from person to person, depending on health, number of family members available to provide support, mobility of the senior, and ability of the senior to continue managing his or her day to day care. Case managers initiate services, whether from inside West Suburban Senior Services, or from outside vendors or other community resources. Case managers maintain an ongoing relationship with elderly clients to assure that services are being provided as agreed to in the care plan. In addition to helping the older person decide which services are needed, case managers help determine what services seniors can afford. If seniors’ life circumstances change, requiring hospitalization, or a change from a single-family home to an apartment, case managers can aid clients in the transition. Case managers are also able to provide general information on assisted living and nursing home care when necessary. The goal of the Case Management program is to assist seniors in developing care plans that will enable them to live independently for as long as possible.
For example, someone recovering from a stroke, who may have been fairly independent, would receive a comprehensive assessment by a case manager. The older person may need home-delivered meals or transportation services. A homemaker may be necessary to help with medications, bathing, and household chores. The case manager’s assessment, along with the client’s wishes and financial considerations, would determine which services are begun, length of time the service is rendered, and which providers would perform the services.
However, Case Management involves more than being a link between clients and services. The strength of the Case Management program is the continuous connections that case managers maintain with elderly clients and the community. This regular contact enables case managers to be most aware of the resources that are available to meet the needs of their elderly clients.
By forging an ongoing relationship with clients, case managers have the ability to initiate, adapt, suspend, or terminate services as necessary. They are in a position to monitor changes in clients’ health needs, as well as the support available from family and friends, the religious community, charitable organizations, and municipal assistance programs. Case managers are available to their clients by phone on a continuous basis during regular business hours.
Case Management assessments are arranged through the request of the individual, through a family member, or in the event of hospitalization, by hospital social service personnel. The case manager, as part of the comprehensive assessment, will determine a senior’s eligibility for services.
By working with seniors, and not just for them, the Case Management program enables seniors to make decisions regarding their lives, and remain vital, contributing members of the community.