Approximately one year ago, this client fell and broke her hip. It also became evident that her dementia had progressed and that she could no longer live alone. Nina with the family’s permission placed a twenty four hour aide in the client’s home to assist with all of her needs. At this time due to the client’s increased complex care needs, Nina’s role as a care manager became much more involved. She was providing medical advocacy on a regular basis by communicating with her physicians, monitoring her appointments, and dealing with the HMO and pharmacy. Nina also coordinated and monitored the client’s household monetary account so that the aides could purchase the appropriate groceries and household services. In addition, supportive counseling was provided to the client, aides and family to help them deal with the numerous challenges that kept changing over time.

The final challenge came last month when this client’s son finally made arrangements to fly her to Maryland to live in an assisted living facility near him. Her son was anxious because he still knew that his mother did not want to move. With lots of support from the care manager, doctor, and nurse’s aides a plan was developed and a date was set for her son and her aide to fly with her to Maryland.

It took lots of advance anticipatory planning time by the care manager to coordinate with the entire allied health team of professionals, the Rona Bartelstone Home Health team and family members to ensure that all the needs of this client would be met both here and in Maryland. Obtaining a photo identification card for her trip really emphasized how this care manager was able to jump through those hoops and navigate the system in order to meet all the traveling requirements for this trip.

The son was most grateful for all of the care and support that his mother and his family received over the years. Most of all, he was happy to finally have his mother residing near him so that they could embark on their “New Beginnings” together.