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Stories from the Front Lines at Aging and Disability Services

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One of Aging and Disability Services’ core programs is case management. Our case managers are social workers who serve more than 14,000 clients every year by assessing their needs and authorizing in-home care hours and other services. But that’s only part of their story. As one case manager put it, “Aging and Disability Services case managers provide the missing piece—we resolve basic needs like housing and food first and then work with health and human services providers to ensure clients get the ongoing help they need to continue living independently.”

The following anecdotes were collected through online interviews with Aging and Disability Services case management teams this summer. Although streamlined to protect privacy, these stories help illustrate the complex challenges that case managers, RN consultants, caregiver support specialists, and social service aides face daily. They are the people on the front lines in maintaining health and welfare of older people, adults with disabilities, caregivers, and family members throughout King County.

Serving people with complex needs

“My client has quadriplegia—he can’t move below the neck but he’s fiercely independent. Without round-the-clock care, his safety was my top concern. I found a way to position a PERS [Personal Emergency Response System] unit that he can activate with his head. I also coordinated unifying services, including caregivers, and health care service follow-up when he had a UTI [urinary tract infection]. Without our services, he would not be able to live alone.”

“We serve adults of all ages who have a broad range of physical and mental health issues. We connect with them in their native languages and arrange for a broad range of services, including DV (domestic violence) support.”

“I’m working with a new client who, in her late 60s, has Parkinson’s-related dementia. She hasn’t left the house since October. When I met her, she hadn’t bathed since November (several months). In her culture, she could not ask her son to help. I arranged for in-home help with bathing as well as a PERS unit that helps reduce her anxiety about being homebound.”

“My client has degenerative disease—Parkinson’s-related dementia, delusions, and hallucinations. I worked to develop a support network, which includes her ex-husband, neighbors, apartment manager, and the fire department. Eventually, because caregivers qualified to meet her needs are difficult to find, my client agreed to move to a long-term care facility. I helped identify an adult family home where she would have someone available to help if needed 24/7.”

Building trusting relationships

“Building trust is so important. Nearly all of my clients have physical and mental health needs (not necessarily illness but chronic conditions) that we have experience managing.”

“Once there’s trust, clients really open up about isolation, lack of support, and cultural and language barriers. When family members trust, we can have a candid conversation about issues like skin, bathing, and toileting. Then we can arrange for the help they really need.”

“My client isn’t all that old—67—but she chooses not to be treated for bipolar disorder. She doesn’t want to talk to a behavioral health specialist. She chases caregivers away—aggressively, once with a broom, all the way to the street. She uses offensive language. A lot of caregiver agencies don’t want to deal with her anymore. I worked with her daughter to get a new primary care provider and set up a care plan. It’s working for now but I’m always on the lookout for new mental health resources.”

“Those of us who serve Seattle Housing Authority residents are seen regularly in the buildings—they know us. This makes a huge difference when we need to help resolve issues that could lead to eviction, like food, mess, and feces on the floor. I’ve helped clients agree to the help they need and arranged with both housing and mental health providers to help them get stabilized. Each time is better.”

“It takes a long time for most of our clients to trust someone new, whether in their home or in a care setting. Paranoia and anxiety are common. Case managers play an integral role as advocates for clients when meeting a new caregiver, health care or social service provider.”

“My client lives in supported housing. He has both physical and behavioral health issues. His explosive outbursts are a barrier to addressing other issues. He doesn’t trust new people. I’m able to provide de-escalation tips to on-site staff. Caregivers must be extremely patient. Teamwork helps!”

“Speaking the same language as my client makes a big difference in establishing trust and providing important information. My Russian-speaking clients really benefit from my coordination with their health care providers. In one assessment, I determined that my client was taking multiple prescription drugs for high blood pressure, received from different health care providers. Fortunately, I was able to sort that out before there was a dire consequence.”

“Most of my clients speak either English or Somali, as I do. I feel such a sense of joy from clients who appreciate that I speak their language and understand their culture. It brings me great satisfaction to advocate on their behalf. I bridge the gaps, getting them the services they need.”

“Case managers build trust and rapport with their clients. That trust is so important when a client is facing eviction. Case managers serve as mediators. We intervene when there is conflict. We help clients avoid having incidents on their record that might block stable housing in the future. We are there to achieve the best outcome possible for the client.”

“Generally, we do whatever we can to help a client continue to live independently. Sometimes the best option is a professional care facility. Recently I worked with a couple—he had dementia and she was adamant about staying home. Their kids were grown and living elsewhere. The family was confused and anxious. We discussed the pros and cons of different long-term care options. The mother was able to articulate her sense of loss—both her husband’s ability and worry about the loss of personal belongings in the future. Her son agreed to store her belongings and visit more often. Eventually, the couple moved into a care facility, which has been easier on everyone.”

“My client called me because he was experiencing random blackout spells. I got him a PERS unit and accompanied him to a medical appointment. He has no one else to reach out to!”

“Clients call case managers for everything, even food stamps! We work to build rapport. Clients know we are their advocates.”

“I have a younger client who lived in transitional housing. It took a small army of ADS staff, but we got her into permanent housing.”

“Sometimes just a pair of clean pants or shoes that have toes intact can have an enormous effect. Clients living in soiled clothes and messy apartments often don’t like how they live but they can’t cope with change. It is awesome to be able to help and see their lives improve!”

Managing behavioral health issues

“One of my clients is young (39) and presents very well but has PTSD and visual impairments and doesn’t trust new people. She’s highly motivated to live independently. Because I know her, I can support her by explaining her condition to other providers. Fortunately, a couple caregivers have built rapport with her now and she’s getting the in-home support she needs.”

“Many clients behave in an explosive way at times—that’s kind of a norm. Yelling is not uncommon. Some are autistic. Some don’t hear well. Most have multiple needs and difficulty communicating what they need. Most are at high risk of homelessness. We work through all of that to get them the services they need to live independently.”

“Some clients have become suicidal when faced with possible eviction but don’t have the capacity to make the changes they need and want without our help.”

“Recently I asked a standard assessment question about suicide ideation. I learned his most recent suicidal thought occurred earlier that day. He was hospitalized but discharged the next day. His mom found him in a closet. He went to a different hospital, where he received care for one week. I’ve helped coordinate therapy and other services. One year later, he is stable.”

“Clients with suicidality would be in the hospital (or worse) if were not for our services.”

Mediating housing, transportation, and emergency service issues

“One client lived in a building that had widespread bedbug infestation. During an assessment, I found out that the mattress and couch had not been removed during treatment. I worked with the building manager, who agreed to treat the unit again and cover cost of moving furniture. I was also able to purchase a vacuum cleaner for my client.”

“My client lives in east King County and visits the adult day health program in Seattle’s Chinatown two to three times each week. This was her only opportunity to get out of her house. She used Access (paratransit services) to get there—sometimes with a three-hour commute, including transfers. She doesn’t speak English and uses a walker. Incontinence issues put her at greater risk of skin breakdowns and UTIs. I contacted Access on her behalf. They ended up providing taxi rides for her—direct from home to her program and back again.”

“My client lives alone in VA housing, with limited services. When I met him, his apartment had more than 20 bags of garbage and flies and other bugs. His dog’s feces were on the floor. I worked with the VA to get his unit deep cleaned so we could get a caregiver in to work with him. I helped him develop a plan to maintain a garbage-free home. He hasn’t bathed yet but has loved wearing clean clothes and expresses excitement about being clean. His caregiver is very patient and supportive.”

“We deal with lots of housing issues, from hoarding to late payments, in order to keep clients in stable housing.”

“I was successful in moving two clients who were on the county’s EMS high utilizer list off that list. When one was hospitalized and then released, she went right back on the list. The fire department saw her 11 times in three days. She lives in a shelter again and has no chance for stability.”

Triaging client needs during COVID

“Every case manager is an essential worker. At the start of quarantine, we called more than 14,000 clients to check their status and triage needs. Because many are homebound and receiving services, a low percentage have been exposed to COVID (less than one percent as of early July).”

“We have hundreds of clients on Vashon Island but a limited number of caregivers. When one client needed a new caregiver during COVID, I contacted eight agencies—all said no. I expanded my search to Pierce County, since there’s ferry service from Tacoma at the south end of the island. I was finally able to identify a new IP.”

“I’ve experienced the same thing in east King County. Whether it’s COVID, the client’s condition, or the home environment, sometimes it’s really difficult to find a caregiver, and that can cause a lot of complications.”

“My client lives with his mother in an apartment. They don’t receive any help from other family members. He can’t work due to back issues and the COVID quarantine. Fortunately, he’s very comfortable in his role as caregiver. To help, I arranged for home-delivered meals and a PERS unit and ordered incontinence supplies.”

“When COVID first started, I was able to arrange for food and meal deliveries for very high-risk clients, including some who were exposed and had positive test results. In isolation, most services stop. Sometimes family or friends can help, but some clients have no one else.”

“Our clients have been so lonely due to COVID quarantine. Many are afraid of losing friends and community. They are so thankful to have someone checking on them, even by phone.”

“Social isolation is a concern always—even more so during COVID. We’re talking to clients, solving their problems, and boosting resilience in many ways.”

“Some of my clients live in fear of COVID. They have stayed home in isolation. Because they’re not moving as much, they’re losing muscle tone, and some are not practicing self-care and taking care of personal hygiene. I’m concerned that some clients are moving into a higher category of care during this pandemic. They’ll need more support in the future.”

Supporting adherence to care plans

“I’ve helped clients connect with a provider for regular health care, set up reminders for them, coached them prior to health care appointments so they communicate what’s most important for the provider to know, and authorized RN consultants when needed.”

“My client was hospitalized for about a month. Before returning home, I was able to set up home meals, a new caregiver, and PERS lifeline. My client is stable at home because of these services.”

“Some clients have such despair; they would give up without the motivational support that case managers provide. If it weren’t for us, some clients would be back in nursing homes and on feeding tubes.”

Serving adults of all ages

“Some of our younger clients live with debilitating conditions like chronic physical pain. Sometimes that’s caused by trauma. There can be a domino effect.”

“Recently I started working with a 26-year-old who had a surfing accident and is now quadriplegic from the neck down. My client’s family only speaks Korean. Mom weighs about 100 pounds; client is probably 180. He’s still in the hospital but thanks to their referral, I was able to use motivational interviewing to determine my client’s goals and set up a care plan that includes a KWA caregiver, from the ground up. We’re just waiting for a hospital bed to be delivered before he comes home.”

“The in-home supports we authorize make such a difference. Safety is a high concern. Having someone from outside handle things like bathing reduces the risk of falls for clients and caregivers. We don’t want both going down!”

“I connected a client who was struggling with disability and depression with a job coach. I was able to look at my client’s diagnoses, talk with him about goals, and then explain to the job coach what support was needed. Eventually, my client had a job!”

“Late last year I started working with a woman in her 50s who is fit and can move fast. She has a dementia diagnosis and had lived at a skilled nursing facility, but her family brought her home. They didn’t understand what she would need. I completed her assessment, determined how many hours of care she could receive, and discussed this with her family. When her needs changed, I authorized more hours, but it still wasn’t enough. Personal hygiene was difficult. Bathing could take three hours, including catching and coaxing her into the bathroom. I identified three caregivers who understood her disease and had the patience to provide the support she needed. Along with her family’s support, she’s doing well.”

“We help younger clients who have addiction problems and have lived in transitional housing. We help identify family caregivers where providers refuse to go due to arrest records and safety concerns. We work with families to resolve care issue. Case management services support clients and their families.”

“Many of my clients have amazing stories. Some are war victims. Some—even while on services—have graduated college and gone to work, going off services. They are amazing advocates themselves.”

Supporting family caregivers

“We help stabilize unpaid caregivers and their loved ones. Our services postpone the need for Medicaid Title XIX services. Often, we’re supporting older people who in turn care for an elderly parent. A bit of respite care can make all the difference.”

“Parents and family members benefit from our support, which can mean they are able to spend more quality time together. And we can connect them with caregiver support services when needed.”

“Families depend on our guidance, empathy, comfort, and support. Sometimes family members don’t take care of themselves. When we see that, we can recommend strategies, including caregiver support services.”

“Many of our clients depend on family caregivers who have sacrificed financially by not working outside the home. We help relieve financial and emotional stress by providing practical, tangible supports like incontinence supplies, transport chairs, and in-home assistance.”

“My 76-year-old client takes care of her 65-year-old brother, who was born with severe physical disabilities and lives with serious health and mobility issues. She invested most of her retirement funds on home renovations to meet his needs. He requires very heavy care—feeding, bathing, dressing, walking, and wheelchair transport to appointments. She provides care approximately 100 hours per week, despite her own health issues. They have no other family. She postponed surgery for herself due to the COVID crisis because her brother would need 24-hour care while she is in hospital. Options are very limited, due to his heavy care needs, and now (due to COVID) it’s even more difficult to find a facility where she feels he would be safe—for a week or long-term, should something happen to her. Meanwhile, the ADS Family Caregiver Support Program provides in-home respite eight hours each week. My client says she doesn’t know how she would manage without my help.”

Saving money, saving lives

“ADS case managers are known for our innovative approaches. I know we are saving the State lots of money by helping our clients continue to live independently.”

“If my client loses his housing due to behavioral problems, he will end up on the street. Without the services we’ve provided, he probably wouldn’t be alive today.”

“Without our services, my client would be evicted. He would have little chance of housing elsewhere, at least not without a significant amount of time living without shelter. He’s burnt too many bridges. I work to give him the stability he needs to maintain.”

“We’re saving lives. Without our help, many of our clients would fail—become homeless or require institutional care.”

“I fear that budget cuts will be made that hurt people with behavioral health issues most. Taking away from people who have the very least just isn’t right!”

The stories shared by ADS Case Management Program staff illustrate the importance of the services each case manager, RN, aide, and specialist provides. It was an honor to listen to them talk about work with clients, each with their own story of survival. Without a doubt, our services make a significant difference—for clients, families, and the community.

Contributor Irene Stewart manages communications for Aging and Disability Services and is editor of AgeWise King County.

Posted in Services