CASE CONFERENCE PRESENTED BY COUNTY OF RIVERSIDE DPSS ADULT SERVICES - - PowerPoint PPT Presentation

RUHS GERIATRIC INTERPROFESSIONAL CASE CONFERENCE

PRESENTED BY COUNTY OF RIVERSIDE DPSS ADULT SERVICES DIVISION

Keeping Our Client’s Safe in Their Own Homes…Sometimes it Really Does Take a Village…

Learning Objectives

• Increase awareness of interagency collaboration with

high-risk cases.

• Provide education regarding DPSS Adult Services

Division programs, In-Home Support Services (IHSS) Adult Protective Services (APS) and how they interrelate.

• Increase awareness of how we balance a client's right to

self-determination with the need for on- going support.

None of the faculty, planners, speakers, providers nor CME committee has any relevant financial relationships with commercial interest There is no commercial support for this CME activity

County of Riverside DPSS Purpose

• Vision Statement: “A County where individuals reach

their full potential.”

• Mission Statement: “ Partnering with communities to

protect and empower vulnerable people.”

• Values: “Accountability, Collaboration, Respect, Diversity,

Integrity, and Customer Focus.”

Who are our ASD clients?

• Elderly clients over the age of 65 and disabled adults

between the ages of 18-64.

• IHSS clients who have been deemed “at risk” of out of

home placement without the benefit of our services in

• place. These clients are medically fragile adults who are

dependent on the care of another for completion of ADLs.

• APS clients for whom a report of suspected abuse and/or

neglect has been generated.

Principles

• Our clients have a right to safety and it is our

responsibility to make appropriate referrals and assist in advocacy as necessary.

• Our clients have a right to accept or refuse services.
• Our clients have a right to retain all civil and constitutional

rights unless a court adjudicates otherwise.

• Our clients have a right to make decisions that do not

harm others.

How can we help?

• In working with our vulnerable clients, we maintain the core values of :

Dignity Self-Determination Least Restrictive Environment Focus on Prevention and Stabilization

IHSS

• IHSS Social worker assesses the needs of the client to

ensure correct authorization of services for the client to remain safely in his home.

• Our client is in need of over 200 hours of IHSS services.
• Our IHSS social worker as a mandated reporter noted

concerns in the home and with the client which prompted a PHN Referral and an APS Report.

IHSS Referral: 1-888-960- 4477

A Case Study and its Concerns

• 65 Year Old, African-American Male
• Resides alone
• Multiple Sclerosis and is Bed-Bound
• Requires assistance of caregivers to meet his needs (ADLs)

(In-home Support Services) IHSS since 6/2000

• Vulnerabilities include:
• Resides alone
• Limited Social Support
• Hx of Bed Sores
• Hx of UTI with Sepsis
• G-tube and Foley Catheter Use
• Hx of Fecal Impaction
• Depression
• Poor appetite
• APS Hx of self-neglect and neglect by others
• Contracted hands/Difficulty Utilizing his Life-Alert

A Case Study and Its Strengths

• Retains the capacity to make his own decisions. (self-

determination).

• Able to state his needs.
• Has the support of IHSS.
• Has a daughter who does not reside locally; however, she

is his POA.

• Is a Veteran and eligible for some services (aid and

attendance/transportation).

• Multi-Agency Collaboration to assist in stabilization.

Public Health Nurse

• A PHN referral was made due to concerns of:
• A non-operational G-Tube
• Bed-sores to the client’s coccyx area
• Fecal impaction
• Poor appetite
• A Foley Catheter and Hx of UTI with Sepsis
• Recommendations were made to the social worker.

Molina Health Care

As a part of the CCI, Coordinated Care Initiative, our ASD has developed an MOU with the health plan which allows us to work in a collaborative manner on our client’s behalf. The work we do together is a bridge to comprehensive care for the client members we serve together. CCT, Coordinated Care team meetings are held via telephone and involve case management and medical professionals familiar with our client’s care needs.

Provisions of services

• Molina Health Healthcare

Terrance Henson, LTSS Manager Vernice Taylor, RN Case Manager

Adult Protective Services

• An APS Report was made to address:
• Instability of Care-Givers
• Hx of Self-neglect to include multiple bed-sores, Hx of UTI with

Sepsis

• Fluctuating capacity
• Limited social support and need for advocacy.

APS Hotline: 1-800-491-7123

IHSS Public Authority

• The Public Authority maintains a registry of providers able

to assist with the hours authorized through the IHSS program.

• Client matched with an appropriate primary care giver

who is able to meet his needs.

• Ongoing mitigation of client and caregiver issues that may

arise.

P.A. 1-888-470-4477

Current Outcome

IHSS adjustment of hours appropriate to his needs. Molina case management services in place to support client on an ongoing basis. Currently compliant with medical appointments, wound care, and has scheduled visits which are upcoming. Stabilization of wound, G-tube consult upcoming, Foley catheter exam and replacement, Pain is managed at this time. Counseled and given resources for V.A. aid and attendance for future care overnight.

Interprofessional Involvement

IHSS PHN Referral CCI Liaison

• utreach to

Molina Health Care Public Authority (P.A.) APS Referral and Involvement

Focused on the Holistic Situation “We are all pieces of the same puzzle"

Please feel free to contact Priscilla with any questions you may have.

Priscilla Bruny Program Coordinator Geriatric Medicine Division P.Bruny@ruhealth.org (951) 486-5623