Nurse Care Management Program
The Nurse Care Management Program provides nursing and volunteer assistance to support older adults and those with disabilities as they strive to cope with complex medical needs, psycho-social crisis, and life transitions which require direct collaboration with health care providers and diverse community resources. We provide these services free of charge.
The Nurse Care Management Program serves approximately 50 persons yearly, many of whom are considered to be at-risk due to advanced age, chronic disease, functional or cognitive impairment, and inadequate or unstable resources (eg. nutrition, finances, health care, support system). It is estimated that 20-30% of individuals living in subsidized senior housing are frail and need assistance with activities of daily living (U.S. Department of Housing and Urban Development). These individuals and their support systems are in need of the ongoing education, facilitation, advocacy and coordination characteristic of care management. Health S.E.T. programs provide outreach not only to identify at-risk persons but to play a key role in helping these individuals and their caregivers to take an active role in attaining or maintaining health and to find meaning and satisfaction in their lives.
The Nurse Care Management Program helps low-income elderly people to adapt to a complex and changing health care system.
An example:
It takes every bit of courage and faith that Holly has in order to just survive. Day after day she spends hours on end going to doctor appointments and waiting for Access-A-Ride. Holly is in constant, excruciating pain from head to toe. She has cancer. She is a brittle diabetic. Her teeth are decaying, broken, and painful. Holly suffered head trauma in a car accident as a child. She was referred by a mental health worker when the hospital cut its high intensity treatment program. In a year's time, her psychiatrist, her primary care doctor, her home care nurse, her personal care provider, and her transportation provider all changed. Holly has Home and Community Based Services but nobody accompanies her to appointments or helps her with paperwork (her vision is poor due to diabetes). The Health S.E.T. Nurse Care Manager is now an ongoing and consistently reliable source of caring and support for Holly. She ensures continuity and coordination of care and provides validation of Holly’s self-worth. A volunteer working in the Nurse Care Management program visits Holly. They watch movies together, go shopping at the mall, and spend time sharing stories and laughing.
The Nurse Care Management Program helps clients obtain comprehensive and affordable care.
An example:
Sam was unemployed and homeless due to vision loss. He was referred to the Nurse Care Management Program by social services. Sam was having difficulty getting the health care he needed. Like many Health S.E.T. clients, Sam found it difficult to communicate effectively with the doctors and nurses at a neighborhood health center. He doubted that he’d ever help for his vision loss. The Health S.E.T. Nurse Care Manager attended medical appointments with Sam in order to makes sure that Sam’s concerns were acknowledged and addressed. Sam ended up having cataract surgery and has regained sight. In addition, the nurse advocate/care manager helped Sam explore housing options. Instead of living in a run-down motel, Sam is now living in an apartment building that offers in-house support services. Health S.E.T. staff obtained donations of clothing, furniture, and kitchen supplies to help Sam get started on the road to a better life.
The Nurse Care Management Program facilitates access to community resources.
An example:
Nancy is a single grandmother with custody of two school-aged grandchildren. She was working full time as a waitress when she learned she had breast cancer. Nancy was referred to the Nurse Care Management Program by a cancer organization because she needed help identifying and accessing care for breast cancer and figuring out how to manage her life during treatment. With limited financial resources and a lot of responsibilities, Nancy felt overwhelmed. Luckily Nancy did have supportive family and friends. The Nurse Care Manager sat down with her and helped her to devise a game plan involving Nancy’s natural support system as well as community resources. Nancy had been under the impression that she would not be able to get care because she couldn’t afford it. The Nurse Care Manager helped her connect with the Colorado Indigent Care Program for her oncology care and obtain financial assistance for household expenses through Sense of Security, a charitable resource for persons with breast cancer. Nancy’s family and friends helped with meals, transportation, and household tasks. Today Nancy and her family are grateful for having made it through a very difficult time.
The Nurse Care Management Program assists and supports clients in preparing for life transitions and adapting to crises.
The Nurse Care Management Program promotes independence, self-determination and optimal quality of life within a holistic framework.
An example:
Pete and Betty were referred to the Nurse Care Management Program through Health S.E.T.’s Health Promotion Clinics because the couple needed assistance obtaining dental care. Their lives quickly changed, however, when Betty was diagnosed with an inoperable tumor and was given only a few months to live. The Nurse Care Manager worked collaboratively with a hospice organization to support the couple, their children and grandchildren, as they prepared for Betty’s death. This support included working with the couples church and apartment building management to hold a celebration for the couple’s 50th wedding anniversary!
The Nurse Care Management Program empowers individuals and their families to achieve competence and independence in self-care and care-giving.
An Example:
Fran was referred by an out-of-state daughter who had visited the Health S.E.T. website. She was concerned about the severe decline in her mother’s physical and emotional health and the fact that she was “unable to get doctors to return phone calls...dropping the ball.” Doctors weren’t communicating with each other and seemed unable to come up with a diagnosis. The Nurse Care Manager helped Fran obtain the information she needed in order to advocate for herself. A volunteer helped organize all the paperwork and provided supported friendly visiting. Fran made phone calls in order to connect with new doctors, schedule appointments, communicate with Social Security, and evaluate options for alternate care. Fran was found to have a progressively debilitating disease and was granted Social Security Disability. As her voice became weak and her physical state more frail, the Nurse Care Manager accompanied her to appointments. The care-giving daughter received respite by not having to leave work to attend doctor appointments with her mother. Fran is still living in her own home with supportive services from the community.