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 Initially, frequency of face-to-face visits is usually weekly and are gradually withdrawn as client/caregiver become more self-sufficient.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.