A Successful NSES Team Approach to Keeping A Senior Independent

When NSES’ Transitions Care Manager Casey Horrigan first met with Bill, a 62 year old Veteran, he was in a skilled nursing facility, recovering from a fall 2 months prior. Although he had been wheelchair bound in his apartment prior to his fall, Bill was optimistic and motivated. During months of hard work in the rehabilitative therapy, he was able to regain mobility with a walker in the facility.

With the help of NSES’ housing coordinator, Diane Moses, an emergency application for housing was submitted to the Housing Authority in June. By July, Bill was offered an apartment. Preparations were put in place for a September discharge and move-in date.

Casey engaged in conversation with Bill to assess his goals and learn how he envisioned his future. “I always want the client to play an active role in decision making. I want to learn about their vision for moving out of a facility and back into the community; then we can plan together and with the help of the housing coordinator and care manager, all work as a team to help achieve the consumer’s goals”, states Horrigan.

With confirmation of Bill’s desire to move into a new apartment, and his motivation to continue to work towards improved mobility, Casey went to work to ensure a successful transition. With help from the MassHealth Choices program, she was able to arrange transitional assistance, including moving services, to transport his belongings to the new apartment. Casey asked Bill to connect with a member of his family to request assistance with packing Bill’s personal possessions in the previous apartment, to have everything ready for moving day. His care manager, Shelby Perrault, was able to arrange Chore services to assist with unpacking boxes. She was also able to arrange Homemaking Service on moving day to help Bill get settled in his new home.

With special permission, a refrigerator for the new apartment was purchased by NSES and covered under the Choices program, as well as a wheelchair, which insurance was unable to cover. Due to Bill’s limited financial resources and limited informal supports, such assistance was crucial to eliminating barriers to discharge and preventing Bill from institutionalization.

Unfortunately, Bill had several falls in the new apartment. Casey spoke with Bill again about helping him look into obtaining a wheelchair accessible apartment. Within a week of requesting a transfer, Bill was offered another apartment. The eternal optimist, Bill ultimately declined the offer in hopes of improving his mobility and not needing such accommodations. He also felt that another elder may have a greater need for the handicapped unit than himself.

With the hard work and dedication of Casey, Diane, and Shelby, Bill’s desire to return to the community and maintain his independence was achieved. Bill has many hobbies and hopes to one day be able to teach a class at the Senior Center. He continues to receive weekly home care service from NSES on the Choices program, and manages many of his needs independently.

Bill was appreciative of all the help he had along the way and has expressed his gratitude toward the NSES staff involved in his case. It’s a great example of the work that the Transitions program seeks to accomplish. Bill was able to avoid institutionalization, his voice was heard and his wishes were honored. Thanks to the team at NSES who made the difference!

Author Info

Jayne Girodat

Jayne Girodat is the Communications Specialist at North Shore Elder Services. Along with ten years in the position of Caregiver Support Specialist at another ASAP, Jayne was a long-distance caregiver to parents for the same amount of time. That experience serves as motivation to better understand the issues of aging and to engage people in conversations about those issues. Jayne's background in teaching contributes to her appreciation of social media as a tool to educate readers on aging concerns. "I love asking people questions. Everyone likes to be heard. When you ask and then listen, you'll find everyone has a story and some of those stories are gems. I think it is particularly important to hear the voices of our older adults. Those are the stories I really connect to and hope to bring to North Shore Elder Services' audience."

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