Aging in Place: An Example
Our Aging in Place solution: How it works
Engagement and online assessment
Mrs. RH receives a tailored a tasteful mailer that speaks to her about falls risks. She fills out a brief online assessment and soon after schedules an initial phone call with nurse Mrs. RH.
Additional assessment conducted via telephone
KR learns that Mrs. RH has recently been hospitalized for pneumonia and diagnosed with COPD. She has been prescribed several new medications that are causing some side effects, including diuretics causing multiple trips to the bathroom at night. Additionally, she has:
- A history of balance problems and a fear of falling
- A walker, but it does not have a seat (Her provider has ordered one, but Mrs. RH does not know how to obtain the new walker)
- A daughter who has provided some in home care, but is not always available
- Not applied for Medicare In-Home Supportive Services
Intervention and care plan
KR and Mrs. RH have worked together over the course of 2 weeks to:
- Change when she takes her diuretics to prevent nighttime trips to the bathroom, reducing nighttime fall risk.
- Contact the durable medical equipment provider for her insurance plan to confirm the order and obtain the new walker.
- Request a physical therapy consult from her PCP to work on improving her balance. We followed up confirming access, weekly therapy visits and strength/balance improvements.
- Set up a monthly communication with her daughter so that Mrs. RH has a better idea of what type of additional help she needs and easy ways to access this assistance.
- Consult with the Sagility APH social worker to assist with applying for IHSS. We followed up to confirm application completed and active engagement has begun.
Outcomes
During a recent follow-up, Mrs. RH reports No falls. As a result, Mrs. RH is a happier, healthier client who is able to remain at home while saving thousands of dollars in avoidable claims expense.
Healthcare LLC, doing business as Sagility™). All rights reserved.
