Reference no: EM132230949

Case Management Action Planning Case Study

A case manager, Marie, is meeting with Michael Cornell, an individual in need of services, and his granddaughter Jennifer. Michael age 86, took a bad fall six weeks ago and has been receiving rehabilitation services at a local nursing facility. Discharge planning was not thorough as Michael insisted he was ready to go home with services in place or not. Jennifer is not able to provide Michael with all the assistance he needs, but is willing to help as much as she can. However, it has become apparent to both Michael and Jennifer that he will not be able to remain at home without assistance. As a result of the fall, Michael had a hip replacement and a broken arm which was put in a cast. He also has diabetes, (two toes amputated in the last two years), and macular degeneration. Michael has become quite confused since his stay at the nursing facility and currently his decision making skills are severely impaired. He needs extensive assistance with dressing, bathing, toileting and transfers. Michael is not eating well and continues to lose weight. Michael tells Jennifer and Marie that he has no energy, feels down a lot and doesnt even care about tending to his garden this year. He previously enjoyed socializing with people and hobbies like woodworking, gardening and painting, but they dont interest him much now. Michael attended the local Congregational Church, but has not been to church services since his fall. He agrees that it might be helpful to talk with the pastor, have people around during the day and is willing to accept services that will help him to be able stay at home. Michael and Jennifer are interested in agency directed services at this time and clearly want to receive case management services. Michael, Jennifer and Marie are now developing Michaels Action Plan together.

Question to Answer:

What goals do you think Michael might have?

Suggested Goals: According to the case study the goal of michael is to get good nursing services like dressing, bathing, toileting and transfers at home so that his health can be better & have people around him during the day. as his grand daughter,Jennifer does not have all the knowledge.she can do what she knows.

For each goal (based on the issues), write a plan including strategies and timeframes

Remember to:

Address the following in the plan:

The processes involved in addressing the clients needs

Recommendations regarding services, supports and referrals

Details of (potential) meetings conducted with the relevant professionals

Continuous improvement strategies

Support from the literature