JFS Care Manager Helps Senior Regain Their Independence and Routine

Rochelle is a 65-year-old woman who has been receiving services from Alpert Jewish Family Service for nearly 15 years. She receives subsidy care management, psychiatry, counseling, friendly visitor and food pantry services, Meals on Wheels, and chore service. She has limited family and social support and minimal finances. A care manager was assigned to her to identify her physical, emotional, and social needs and develop a comprehensive care plan.  

Rochelle has had a history of falls, including three falls in the past few months. She broke her hip last September and her ankle in December. Both falls occurred at her home. Her most recent fall occurred in January, and she was hospitalized for a week.   

Her care manager has been advocating for Rochelle at the hospital and rehab levels to ensure she receives the care she needs to prevent further falls. She has also been working with Rochelle to address the barriers to her independence and return home.   

Recovery progressed, but she continues facing challenges. She is struggling to manage her diabetes and take her medication as instructed. Not using her walker led to subsequent falls, hospitalizations, and a return to rehab. Mentally, she struggles to cope with her recent falls and the loss of her independence. Her care worker worked with Rochelle to develop a plan to manage her diabetes and use her walker as instructed.   

Discharged from rehab, Rochelle is now living at home for seven consecutive weeks. Her care manager continues working with Rochelle to help her stay safe and independent at home. They arranged for home health services, including an RN for diabetic teaching and a home health aide to provide support with transportation, grocery shopping, meal preparation, housekeeping, and bathing to come into the home and help Rochelle.  

Rochelle’s care manager is a valuable resource for her. She gives her the care and support she needs to live a safe and independent life. She resumed driving and returned to the foster grandparent program on a modified schedule. Rochelle is happy to return to living in her house and resume her regular activities. It is so rewarding to see that she has returned to doing what she loves the most. 

Overall, subsidy care management aims to improve the health and well-being of individuals like Rochelle, who may face barriers to accessing necessary services and resources. By providing comprehensive support and advocacy, subsidy care managers can help clients achieve greater stability, independence, and overall quality of life. To learn more about Alpert JFS and Care Management, go to www.alpertjfs.org/for-adults/case-management/.