An elderly woman is becoming more and more forgetful. Her daughter, who works full time and cannot see her mother but once a week, fears that her mom is no longer taking her medications correctly. The daughter is also noticing that her mom is losing weight, she is sleeping more than usual and her personal hygiene is deteriorating.

Typical home health care response:

Skilled Nursing could be implemented. This would allow a nurse the opportunity to perform such interventions as:

• Identify possible underlying causes for the decrease in her mental status, such as infection, and notify the physician of findings.
• Assess the client’s ability to manage her medications effectively and implement strategies to promote as much independence as possible with the task.
• Assess nutritional status and implement strategies to increase client’s food/fluid intake.
• Establish the level of assistance required to keep the client safely in her home and coordinate care with the staff, family or alternate caregivers to ensure her needs are being met.

Physical/Occupational Therapy Evaluations could be implemented to identify and address any functional deficits, with the goal of increasing the client’s ability to remain safe and independent in the home setting.

Home Health Aide services could be initiated to assist patient with bathing, dressing and other personal care, until the client demonstrated an ability to safely perform the task independently.

Medical Social Work Evaluation could be ordered to establish which community resources, such as meals on wheels, are available to the client.

Result: With assistance from home health, the client’s medications are successfully managed, her mental and nutritional status improve and she begins to become more active and take better care of herself. Her daughter is taught to fill her mom’s med minder once a week and to identify signs and symptoms of complications that could indicate another deterioration in her status. The medical social worker established meals on wheels and identified a benefit available to the client through a long term care policy she purchased years ago. A referral was made to a private caregiver service and the client now receives 12 hours of sitter services a week. Because home health care was able to identify and coordinate care with all available resources, the client is able to remain safely in her home.