Case Example
Mr. Smith
Mr. Smith is a 79-year-old man living independently in a senior apartment. Following the death of his wife two years ago, Mr. Smith's mental health has declined. He has a history of depression, anxiety, and bipolar disorder, and has recently been diagnosed with leukemia, now in remission. His family is concerned about his increasing symptoms, including signs of dementia and memory loss. Their long-term goal is for Mr. Smith to find joy and meaning in his life.
Medical Records Review
- Objective: Obtain copies of Mr. Smith’s medical records from various facilities.
- Action: The Registered Nurse (RN) will review these records to understand Mr. Smith’s medical and psychological conditions comprehensively and oversee his medical care.
Dementia Evaluation
- Objective: Conduct thorough evaluation and testing for dementia.
- Action: The Care Management team will work with the family to obtain an accurate diagnosis. Initial screening tests, such as the Mini-Mental Status Exam, will be administered by the ECC social worker. The social worker will also provide support and resources, including online support groups and educational materials for the family.
Mental Health Counseling
- Objective: Address Mr. Smith’s depression, anxiety, and bipolar disorder.
- Action: The licensed social worker will conduct 1:1 counseling sessions with Mr. Smith, framing them as informal “visits with a friend” rather than clinical therapy. These sessions will focus on engaging Mr. Smith in meaningful conversations and activities, addressing his emotions, and coping with loss and transitions.
Psycho-Educational Support
- Objective: Assist Mr. Smith in understanding and managing his dementia.
- Action: The social worker will provide psycho-educational support to help Mr. Smith and his family understand the stages of dementia and develop coping strategies.
Psychiatric Treatment Coordination
- Objective: Ensure continuity in psychiatric care and medication management.
- Action: The Care Management team will partner with Mr. Smith’s family to monitor his behavior changes, communicate with his psychiatrist, and adjust his medication as needed.
Ongoing Support and Communication
- Objective: Maintain open lines of communication and adapt the care plan as needed.
- Action: The Care Manager will facilitate communication through email, phone calls, or group meetings. Services will be tailored based on feedback from Mr. Smith and his family, with the flexibility to adjust or terminate the care plan if necessary.
