Janet Brush, Managing Director of Senior Alternatives
"Janet, your dedication and kindness have made you a role model for geriatric social workers in our community. Through your leadership, you have successfully created an organization that operates out of compassion for the client and family."
— Director of Social Work at local senior social service organization
"Senior Alternatives has provided our family with excellent service - both in crisis management and supportive care. Carolyn Lonner has become like another daughter to my disabled brother. We have complete confidence in their professional care."
— Sister of client

A Case Study

The following case study illustrates the Care Management and home Care Giver process when working with Senior Alternatives.

Please note our case study disclaimers:

  1. The identities of those persons portrayed in this case study have been changed out of respect for privacy
  2.  The following case study is not intended as advice on home care, senior care, care management, dementia or medical instruction. Actual Care Management and home care services are unique to each of our client’s needs.
  3. The following case study, and all digital content located at www.bayareaseniorcare.com, is protected by U.S. copyright laws; it’s unauthorized duplication and/or reproduction, or other acts of infringement, will be pursued to the fullest extent possible.


Client Description

Mr. Smith (87) and Mrs. Smith (88) were married for over 50 years.  The couple had no children and had lived together in the same home throughout their marriage.  Their one still-involved relative, a niece named Frances, was concerned that her aunt needed support and respite due to her husband’s physical and cognitive decline.  However, Mr. Smith had never been formally diagnosed with dementia and his physician had not referred him to a neurologist, despite significant word loss and difficulty communicating.  The Smiths had been going to the same physician for 30 years and “trusted him.”

A Senior Alternatives Care Manager (CM) initially set up an appointment with Mr. and Mrs. Smith and Frances.  Mrs. Smith insisted they were doing fine and she was working hard with Mr. Smith on his speech.  She said they took care of each other and he was still able to help her keep the house in order.  She was intelligent with a sharp sense of humor.  She mentioned that Mr. Smith liked to keep busy and might benefit from getting out of the house more and having some other companionship.  She was a self-described “home-body” and enjoyed reading.  He took walks by himself and had given up driving, except for the occasional short drive to the market with her navigating.  While he had not gotten lost, Mrs. Smith worried that she wouldn’t know if something happened to him.  Although she seemed exhausted during the initial meeting, she insisted that she was doing “just fine.”

Issues to Address

Below is a list of issues that came up over a two-year period of working with Mr. and Mrs. Smith.  These issues were addressed both individually and as parts of a larger whole, namely the Care Plan.

  1. Mr. Smith demonstrated extreme frustration over his communication difficulties and problems handling his finances and numbers.
  2. Mr. Smith became angry with the presence of any Home Care Staff in the home.
  3. Mrs. Smith continued to insist that she was fine and only needed minimal help, despite being overwhelmed and exhibiting signs of exhaustion and extreme stress.
  4. Several items around the home needed repair but Mr. Smith could no longer manage them.
  5. Mr. Smith began to verbalize his express wishes to die.
  6. Mrs. Smith attempted to avoid any Neurology appointments for her husband.  Mrs. Smith also would not accept the Neurologist’s frank conclusions about her husband’s dementia.
  7. Mrs. Smith spent many nights awake with her husband, incessantly worrying over him.
  8. Mrs. Smith fell, suffering a concussion and broken wrist. She had to go to a Skilled Nursing Facility.
  9. The SNF tried to discharge her when her Medicare benefits expired.
    1. Mrs. Smith was very anxious about returning home to her declining husband.
    2. She became very depressed and angry with the SNF staff.
    3. She had troubles making decisions on her own, most likely due to the concussion.
  10. After returning home, Mrs. Smith exhibited bouts of paranoid delusion, oftentimes combative with Caregivers over their normal care for her husband.
    1. Mr. Smith’s agitation increased in reaction to Mrs. Smith’s agitation over his decline.
  11. Mrs. Smith refused her medications on a daily basis.
  12. Mrs. Smith refused to leave her bed as her husband declined even further.
  13. Mr. Smith deteriorated dramatically near the end.

Our Actions

  1. Our Care Manager agreed to move slowly at first so as not to overwhelm the Smiths.  She also referred Mrs. Smith to several community resources designed to support her situation.
  2. A Caregiver was introduced to visit the Smiths a few times a week for short periods.  This allowed our Care Manager to keep better tabs on the Smiths, implement a Care Plan designed to support the Smiths and provide needed assistance around the home.
  3. Our Care Manager also helped Mrs. Smith to locate and meet in her home with an Elder Law Attorney that transferred financial responsibility to their niece and also create a Power of Attorney for Mr. Smith listing his wife as primary and their niece as back-up.
  4. Our Care Manager next introduced a local well-liked handyman familiar with older adults and able to make repairs in an unobtrusive manner.
  5. Our Care Manager then obtained a referral for home health physical therapy and worked with Mrs. Smith to increase the frequency and duration of care giving so that Mr. Smith could improve his strength and be safer around the home.
  6. While Mrs. Smith reacted unfavorably to the neurology assessment, she was awakened to the need to better understand dementia and her husband’s decline.
  7. After Mrs. Smith’s fall, 24-hour care giving was implemented to maintain his safety in the home and to help him visit his wife in the Skilled Nursing Facility (SNF).  Simultaneously our Care Manager worked with Mrs. Smith to advocate for the best treatment in the SNF.  She returned home to her husband after a five-month recovery process.
  8. During Mrs. Smith’s adjustment to being back home and subsequent combative behavior, our Care Manager introduced a Psychiatrist to examine the Smiths’ medication regimen.  Through adjustment of the medications they took, and enlisting an RN to oversee the medication administration, many of Mrs. Smith’s new behaviors were mitigated.
  9. During the final stages of Mr. Smith’s decline, our Care Manager brought a hospice team into the Smiths’ home to ensure Mr. Smith’s comfort and Mrs. Smith’s understanding of and coping with the dying process.

The Client Today

The relief of seeing Mr. Smith out of emotional and physical pain was life-changing for Mrs. Smith.  She began to want to get stronger and get out of bed more often.  She agreed to have a Physical Therapist visit her to work on exercises.  She showed interest in getting out of the house and started joking around with the Caregivers more.  She wanted to get new hearing aids and an eye exam so that she could better engage in life.  She now wants to take her medications.  While she shows obvious signs of grief, she is able to work through it by sharing stories with her Caregivers and family.


Meet the Team that made this happen.

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