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Write a Case Management Plan on "Social workers conduct Aged care assessment and are involved in care planning, monitoring and evaluating the service to clients".
Assessment of Care Needs
The 92 year old Caucasian female, Lorna, is depicted with certain care needs. She has been admitted to a hospital with chest infection, leg oedema and unsteady mobility. She has been reported to be depressed and she lacks the energy to go out. She has been spending her time largely at her home. It has been seen that although Lorna was deemed medically fit to return home, some concerns are there on the part of the caregivers. As there is a high chance of falls on the part of Lorna, the caregivers suggest that someone should become her caregiver and should reside at her home or else Lorna should be relocated to an aged care facility. Though Lorna supposed that her neighbour would be helping her out in this respect, the social workers and the caregivers assumed that her neighbour was not at all aware of such guesses that Lorna is having. It should be noted in this respect that everyone’s need is different and different patients need different approach to care-giving. Some people have specific cultural needs while some others have specific religious needs in terms of receiving care. It is in this respect that one must take into account the fact that the aged population has distinct needs for care and such needs should be appeased and met by the care-providers and caregivers. In terms of aged care giving (as it deemed needed in the concerned case scenario) it should be taken into account that the need of aged care-giving is infused with perils that are both emotionally and physically challenging. From time to time “carers may need some extra help and support. This could include counselling or independent aged care advocacy for you as a carer, or respite services for the person you care for – which would allow you take a break. Respite care can also give the person you care for variety and extra social opportunities” (Australian Government, 2018). Moreover, considering the case scenario it must also be noted that Lorna’s foster daughter, who has been supposed to contribute to the caregiving process, has concerns for diabetes. It has been observed that prior to discharge of Lorna, Lillian (Lorna’s foster daughter) has become unwell and had been submitted to hospital due to illness and concerns with her diabetes. Lorna and Lillian both stayed in the hospital and during her stay at hospital she had been reporting that she was unable to take care of Lorna due to her own health concerns including diabetes, hearing loss, kidney disease and back pain. Keeping this fact in mind, it has been noted that Lillian is also very much in need of care just like her foster mother.
Care Plan and Intervention Strategies
Now, considering Lillian’s health issues it has become clear that Lorna is in serious need of aged care and someone should be identified as her caregiver. Usually, in terms of aged care, some specific options are kept open for the care-receiver. In this respect, Lorna has the option to stay in her own home and receive services meant for supporting her to live a health, safe and independent life in the comfort of her own home (Silver Chain, 2017). Such services are also meant for keeping Lorna connected within her community. Then she has the option of transitional and short term care. In this respect the care should be provide to Lorna in her own home and this would be meant for supporting her recovery after a hospital stay or for helping her in regaining her confidence and ability to continue living independently at home (Silver Chain, 2017). Furthermore, considering the problems related to care-giving to Lorna, she can be suggested to take part in the residential care process. The care in a residential facility should then offer a supported environment whey Lorna is unable to live independently at home where help is available when Lorna needs it (Silver Chain, 2017). Moreover, some other factors have to be considered while preparing a care plan and intervention strategy for Lorna. The care plan and strategy should be formulated in such a manner that the aged individual can receive the care in an appropriate manner and enjoy the benefits of such care-giving process. Certain services should be rendered to ensure the wellbeing of Lorna in terms of taking her care and it should also be noted that such services should constitute the care-giving intervention and planning strategy. There must be first a comprehensive assessment of the medical condition of Lorna. In this respect it must be noted that as her foster daughter has been assumed to be taking her care-giver role and as she is not ready to take up Lorna’s responsibilities due to some specific medical conditions; Lorna’s step daughter should be also provided with some specific care means and this must include comprehensive assessment of her medical conditions. But for Lorna, it would be not feasible to get confined within the boundaries of comprehensive assessment of the existing medical conditions. Lorna should be assessed for medical conditions through a process called complex medical review. A complex medical review of her medical conditions should be performed in order to determine what types of ailments Lorna is suffering from. In respect of providing care to Lorna, the health care providers should strive for arranging family meetings. In the intervention strategy the practice of arranging for family meetings should be given importance. This is primarily because; family members of aged patients need to be empowered and involved in the care-giving process and such meetings should be thoroughly participated by caregivers (including the nursing practitioners who would be providing care to the concerned aged individual/s). One must take into account the fact that, “Family meetings are one way in which families can be involved, empowered and supported by nurses. They can be a proactive way of managing and planning care but unfortunately are often instigated only when problems arise” (Care Search, n.d.). It has be made sure by the care providers that in case of providing care to Lorna the effort of arranging for family meetings is proactive and not reactive in nature. Moreover, such family meetings should be arranged by considering referral to palliative care, confirmation of disease progression, discontinuation of treatment or when maximal medical management has been reached, discharge is planned from an inpatient setting, patient’s condition changes and goals of care need re-assessing, etc (Care Search, n.d.). Moreover, complex medical review is very much needed in order to provide proper support to the medication regime that is meant for reviving the health condition of Lorna. If Lorna is determined to be eligible primarily for residential care then her medical condition must be re-evaluated and the complex medical review should be performed to detect if she is suffering from any age-related diseases (that are considered as natural and usual occurrence). In respect of determining the treatment regime in the residential care setting the complex medical review should be conducted. In this respect it must be noted that “People are rarely admitted to residential care facilities for social reasons alone. Dementia, chronic illness and physical disability are the major determinants of admission, and compulsory preadmission assessments ensure that this is so” (Australian Society for Geriatric Medicine, n.d.). It must be noted that medical evaluations and assessments are needed in order to make it easier for aged patients to gain proper access to a broad range of integrated high quality health services. In this respect one must take into account the fact that, “For the physical and mental health of residents there is a need for access to a broad range of integrated high quality health services including, but not limited to, genrontic nursing, primary care medicine, geriatric medicine; psychiatry of old age; palliative care medicine; dentistry; optometry and ophthalmology; physiotherapy; occupational therapy; speech pathology; podiatry; audiology; dietetics; and psychology” (Australian Society for Geriatric Medicine, n.d.). Complex medical review should be a part of the intervention strategy also because of the efficacy of the outcomes of such review. Such reviews can make the health care providers aware of many medical conditions prevailing with the patient and such symptoms might include behavioural symptoms of dementia; chronic pain; depressive disorders; urinary incontinence; hip fractures risk; skin ulcers; cardiorespiratory conditions and palliative care needs (Australian Society for Geriatric Medicine, n.d.). The aged patients “require the development, institution and adherence to multidisciplinary clinical practice guidelines and valid outcome indicators. Therefore a collaborative inter-professional mechanism for integrated guideline development must be established for this population” (Australian Society for Geriatric Medicine, n.d.).
Moreover, considering the social conditions of Lorna and considering the medical condition of her foster daughter it is quite feasible to recommend Lorna for residential care setting. It has been learned that first it was assumed that Lorna would be taken care of by her foster daughter. But the deteriorating health conditions of her foster daughter really do not support the assumption. It has been found that Lorna’s step daughter is not in a medical or psychological condition that should be deemed suitable for providing care to Lorna. Hence, Lorna must be recommended to be shifted under residential care. There are several reasons why Lorna should be placed under residential care process. Usually, it is seen that before making decision of shifting an aged individual under residential care some inquiries have to be fulfilled. For an instance, it has to be determined if the aged person needs assistance in eating, toileting, bathing, dressing, grooming, walking, transferring, preparing meals, shopping, transportation, housekeeping, preparing medication, taking medication, bill paying, using the telephone, etc (Alliance on Aging, n.d.). It has also be determined if the aged individual is incontinent in bladder; if the individual is incontinent in bowel; if the individual wander off; if the individual stay awake during the night; if the individual show combative behaviour like shouting, hitting, etc.; if the individual require tube feeding; if the individual requires skin care treatment for an advanced stage bed sore; and if the individual require frequent assistance in transferring to prevent falls (Alliance on Aging, n.d.). It has been observed that Lorna has been suffering from many of the symptoms described above and adding to them, the social condition of Lorna, which makes it impossible for her to remain alone at home without having the access to care, also makes it quite imperative for recommending Lorna for residential care. It must be noted that at the age of 92, Lorna has high chances to develop progressive dementia and based on this assumption the decision made to put her under residential care seems quite rational and logical. It should be noted that “Progressive dementia, such as in Alzheimer’s disease, are health conditions that require proper treatment and management. In many cases, the appropriate management can be best delivered in Residential Care Facilities for Elderly (RCFEs), with special settings equipped to care for dementia patients” (Alzheimer’s Association, n.d.). Considering the chances of development of progressive dementia in Lorna, the health care providers should recommend her for residential care specially meant for elderly people. The consent of Lorna’s step daughter is needed here, but the decision of recommending her to residential care must be upheld. This is primarily because; “The best modern dementia care RCFEs are specially designed to provide a safe and soothing environment, where residents are attended to and monitored around the clock, but still have the feeling of being at home. Staff is trained to be personable, patient and later to any signs of discomfort or distress” (Alzheimer’s Association, n.d.).
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It must be noted that some ethical considerations have to be emphasized before putting Lorna under resident care. Lorna is an individual and every individual’s dignity should be respected and upheld. For such purpose consent must be obtained from Lorna that would describe her willingness to give assent to the decision of transferring her to a residential care setting. Such consent is meant not only for empowering Lorna but also for ensuring that ethical practices have been conducted in terms of planning for care for Lorna.
Advocacy and role of a social worker
A social worker should advocate for the transfer of Lorna to a residential care setting. The social worker should continue with such advocacy keeping in mind the need of Lorna to be under someone’s vigilance in a phase where her step daughter is unable to take care of her. It must be noted that a social worker should play a crucial role in determining the future care-giving prospects for Lorna primarily because of the nature of the social worker’s profession. In this respect it must be noted that “The social work profession operates at the interface between people and their social, cultural, physical and natural environments while recognising the impact of the psychological, social, political and economic determinants on health and wellbeing” (Australian Association of Social Workers, 2015). It is due to such nature of the profession that a social worker must advocate for a gradual recovery in Lorna’s health by recommending her to get admitted in a residential care setting. Moreover, the social worker must also pay regular visits to Lorna to ensure that her care has been taken properly and that she is reviving. Such an action on the part of the social worker should be deemed necessary in the context of upholding the principles and ethics of social work profession. And considering all such aspects the role and advocacy of the social worker in this case should be given much importance. Social workers need to support such social causes that are meant for bettering the lives of individuals who have approached the last phase of life.
References
Alliance on Aging (n.d.). How Do I know If Residential Care Is Needed? [online] Available at: http://allianceonaging.org/wp-content/uploads/2011/12/OMB-How-Do-I-Know-if-Res-Care-is-Needed-05-2012.pdf [Accessed February 20, 2018]
Alzheimer’s Association (n.d.). Planning for Residential Dementia Care. [online] Available at:
https://www.alz.org/cacentralcoast/documents/2-Planning_for_Residential_Dementia_Care.pdf [Accessed February 20, 2018]
Australian Association of Social Workers (2015). Scope of Social Work Practice: Social Work in Aged Care. [online] Available at: https://www.aasw.asn.au/document/item/8305 [Accessed February 20, 2018]
Australian Government (2018). Caring for someone. [online] Available at: https://www.myagedcare.gov.au/caring-someone [Accessed February 20, 2018]
Australian Society for Geriatric Medicine (n.d.). Position Statement No.9: Medical Care for People in Residential Aged Care Services. [online] Available at: http://www.anzsgm.org/pdfdocs/position_statements/PositionStatementNo09.pdf [Accessed February 20, 2018]
Care Search (n.d.). Family Meetings. Retrieved February 20, 2018, from https://www.caresearch.com.au/caresearch/tabid/1446/Default.aspx
Silver Chain (2017). Aged care needs. [online]. Available at: https://www.silverchain.org.au/aged-care-needs/ [Accessed February 20, 2018]
Alzheimer’s Association (n.d.). Planning for Residential Dementia Care. [online] Available at:
https://www.alz.org/cacentralcoast/documents/2-Planning_for_Residential_Dementia_Care.pdf [Accessed February 20, 2018]
Australian Association of Social Workers (2015). Scope of Social Work Practice: Social Work in Aged Care. [online] Available at: https://www.aasw.asn.au/document/item/8305 [Accessed February 20, 2018]
Australian Government (2018). Caring for someone. [online] Available at: https://www.myagedcare.gov.au/caring-someone [Accessed February 20, 2018]
Australian Society for Geriatric Medicine (n.d.). Position Statement No.9: Medical Care for People in Residential Aged Care Services. [online] Available at: http://www.anzsgm.org/pdfdocs/position_statements/PositionStatementNo09.pdf [Accessed February 20, 2018]
Care Search (n.d.). Family Meetings. Retrieved February 20, 2018, from https://www.caresearch.com.au/caresearch/tabid/1446/Default.aspx
Silver Chain (2017). Aged care needs. [online]. Available at: https://www.silverchain.org.au/aged-care-needs/ [Accessed February 20, 2018]
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