Nurse Case Managers
Older Adults, Healthy Results nurse case managers do the following:
- Provide care coordination for clients who lack the support, functional capacity, and resources to be able to perform these activities themselves.
- Case management interventions are intended to improve care coordination, enhance client safety, well-being, and quality-of-life, while reducing the fragmentation of care across different settings.
Services may include:
- Home visits
- Multi-domain geriatric assessment
- Fall prevention
- Medication review
- Linkage to community-based resources and supportive services
- Health education to support self-management of chronic health conditions
- Health navigation (especially for complex workups and multiple appointments)
- Family/caregiver support and education
Frequency of "touch": services are designed to be intensive. Initially, frequency of face-to-face visits is usually weekly and are gradually withdrawn as client/caregiver become more self-sufficient.
Length of services: nurses generally work with their clients for 6 months or longer depending on the client’s ability and willingness to progress toward goals. Aim is for the client to “graduate” when longer-range, sustainable supports are in place.
Limited capacity: Since OA/HR is a small team of public health nurses working to meet the needs of a large population of vulnerable older adults, we may maintain a wait list. Referred clients are contacted when space opens up on our caseload and we are able to accommodate new intakes.