by Marcy Morgenbesser, LICSW
Alice, 67, has bipolar disorder and lives alone in a subsidized senior housing community. She has been a CJFS client since 2017, receiving Personal Care and Care Management services, Counseling and riding the Buz-A-Bus.
When the pandemic hit, CJFS suspended face to face services, but Amy, Alice’s CJFS Social Worker, continued to check in with her by phone to ensure her needs were met. About a month into the pandemic, Amy noticed that Alice’s thoughts seemed confused, and it soon became clear that she was experiencing delusions. Amy quickly contacted Alice’s daughter, who lives in New York, and together they were able to convince Alice to go to the emergency room.
Ultimately it was determined that multiple urinary tract infections were the cause of the cognitive issues. However, due to her isolation and subsequent illness Alice’s psychiatric medications were also affected. Throughout her hospitalization, Amy served as a coach to Alice’s daughter, guiding her and enabling her to advocate for her mom. Eventually, Alice’s condition stabilized, and she was discharged with the resources in place for a successful transition back home.
Without CJFS’ Care Management program, Alice could have easily become one of the non-COVID tragedies of the pandemic – people who did not receive care for their non-COVID ailments during the pandemic, sometimes with devastating consequences. Even though the pandemic prevented Amy from visiting Alice at home or in the hospital, her regular check-ins with Alice made all the difference.
It’s impossible to talk about the work of CJFS without using the term “Care Management.” It’s at the heart of all we do – and yet, because it can take so many forms, Care Management can be challenging to understand.
So, what is Care Management? Care Management can include a range of activities that help individuals, families and caregivers manage physical health, mental health and social needs.
What are the goals of Care Management? While the goals of care management are unique to each client and his or her circumstances, the overarching goals of care management are
-to improve health and mental health by increasing access to care and supporting preventative and ongoing care
-to increase and support independence by putting resources into place to ensure safety and quality of life while living in the community
-to provide support and guidance in understanding the complex systems and network of resources available
-and to honor self-determination through involvement in one’s own care, as able.
At CJFS, our team of Social Workers has extensive experience with providing Care Management services. Supports and services from CJFS may include:
-Assessing needs, strengths, goals and challenges
-Conducting home visits and outreach
-Coordinating referrals and appointments and providing assistance traveling to appointments
-Facilitating the exchange of information between health care providers, caregivers and other service providers
-Providing guidance and support during transitions of care
-Navigating the health care and health insurance systems
-Managing referrals to community and government resources for such needs as housing, financial assistance, government benefits and food
-Advocating for improved access to resources, addressing challenges to accessing services, highlighting high priority needs of the people we support and “get things done” on behalf of our clients.
In our mobile society, older adults often live far from their immediate families, leaving them to manage physical and mental health challenges on their own. CJFS Care Management works with clients and their families to ensure that older adults receive the care they need when they need it, with the goal of preventing avoidable complications and helping clients continue living independently.
The licensed clinical social workers of CJFS are experts in providing Care Management for older adults and support services for their families. Have questions? Contact Marcy Morgenbesser, LICSW, firstname.lastname@example.org or 205.278.7101.