Most of us believe that we will be young and in control of our health, finances and welfare forever. This rather healthy delusion allows us to focus on day-to-day priorities. However, as time passes and with the normal aging process, we may lose our capacity to make sound judgements that foster quality of life for ourselves and for those who care about us (relatives, friends, etc.) and those who may depend upon us (children, pets).
Proactive planning enables us to make informed decisions free from stress. If a crisis occurs, we are then prepared with an action plan, based on the documented choices. Selecting between a few possible options becomes easier than trying to solve a very big puzzle with scattered pieces.
Before we become mentally, spiritually, or physically frail, trusted advisors should be chosen. A potential network of people and organizations who stand ready to help should be in place. We all need some help from time to time. Acceptance of help, from those who care about us, remains a huge challenge for many since our culture promotes independence and self-sufficiency.
As unique children of God, we have different expectations, desires and needs. We should respect and honor ourselves and others as we cope with successful aging.
Holistic Elder Services Case Study
Case Study 1st visit February 2016
89 year old man living in bi-level ranch home near mountaintop in Columbus, NC – driving, maintaining household, independent in ADLS & IADLs, but starting to struggle
Neighbors only local support system; son and all other family in Dallas, TX area
Diagnoses: Coronary artery disease (sternotomy with valve repair), hypertension, chronic atrial fibrillation, GERD, mild glaucoma, dementia, mild hearing loss, BPH, R hand weakness /decreased dexterity, skin cancer
1/28/16 hospitalized for UTI – St. Luke’s Hospital & Spartanburg Medical Center
Medicare home health RN, PT for few weeks
Care Manager coordinates & monitors
9/2016 Assisted living residence found for him in Dallas area when he visited there
Client expresses reluctance and family finds him independent living apartment in Dallas area
10/2016 Client decides wants to stay in NC home
Care Manager coordinates, monitors
12/2016 Dementia worsening, decreased endurance, sleeping more
Care Manager monitors
1/2017 Travels to Canada alone to see friend – snow storm, power outage – many challenges!
1/20/17 Admitted to ER St. Luke’s Hospital post fall; Medicare home health RN, PT few visits; getting “overwhelmed” with mail, trying to manage household alone, etc.
Care Manager monitors, educates, coordinates
Medic Alert in place; dementia worsening, more fatigue; appointment with neurologist 3/9
Care Manager coordinates, monitors
3/21 Visit @ house – URI sx.? Called primary care MD to relate information – appointment 3/22
Care Manager advocates, monitors
3/23/16 evening taken to ER Pardee Hospital & admitted: tachycardia, fever, cough, difficulty swallowing, fatigue, dehydration
Care Manager advocates, educates
Diagnosis: aspiration pneumonia IV antibiotics, therapies
3/28 MOST form completed Planning for at home care v. assisted living v. skilled nursing
Care Manager advocates, educates
4/1 Son & daughter-in-law visit from TX; Scramble to find POA documents, educate themselves about estate planning/Medicaid
Care Manager advocates, educates
4/5 Transferred to skilled nursing facility in Mills River 4/9 suicide ideations
Care Manager advocates, educates
palliative care, psych consult Therapies “institutionalized” – socialization impaired
Care Manager advocates, educates
5/3 to be discharged to assisted living facility in Columbus or Arden? Son to visit from TX
Much stuff in house to organize/sort/discard/move!
Aging Life Care Managers Provide Varied Expertise
