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 Focus on Prevention and Stabilization Least Restrictive Environment
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 Currently compliant with Molina case IHSS adjustment of medical appointments, management services in hours appropriate to his wound care, and has place to support client on needs. scheduled visits which an ongoing basis. are upcoming. Stabilization of wound, G-tube consult Counseled and given upcoming, Foley catheter resources for V.A. aid exam and replacement, and attendance for future Pain is managed at this care overnight. time.
Interprofessional Involvement IHSS APS PHN Referral and Referral Involvement CCI Liaison Public outreach to Authority Molina (P.A.) Health Care
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
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