Success Stories

Ms. K and the AgeWell New York FIDA Plan

Ms. K is a 94-year-old female, is a FIDA member through AgeWell New York. She lives with her nephew on the second floor of a private apartment building, which has an elevator for tenants. She has another nephew who lives next door and both family members are involved in her care and part of her FIDA Inter Disciplinary Team (IDT). Her nephews prepare her medications weekly and she takes them with aide reminders. Ms. K is diagnosed with chronic kidney disease, dementia, anxiety disorder, primary hypertension, and has urinary and bowel incontinence, which requires her to wear diapers and liners. She has also had a terrible fall two years ago, resulting in a hip fracture requiring hip replacement surgery and subsequently admission into a skilled nursing facility.

Ms. K now has difficulty walking - she can transition from a seated to standing position while holding a walker, but requires physical assistance to walk around due to poor balance. Her Case Manager (CM) has instructed her family members on fall and safety precautions as well as home safety. She also requires encouragement to grab objects because of her poor coordination and muscle weakness and needs assistance in taking care of her personal hygiene or getting dressed. Lastly, Ms. K is on a restricted diet and is not allowed to have bananas, citrus fruits, or dairy.

During a routine IDT, Ms. K´s nephew informed her CM that his aunt needed a refill on incontinent supplies and voiced his concerns about his aunt´s care. "I want my aunt to be more independent and try to do more for herself." He explained. "It would be better if she could become strong enough to get up and go to the bathroom; this way she will utilize less incontinent supplies such as diapers or liners." Ms. K´s CM continues to help with care, reviewing her over-the-counter (OTC) card benefits and explaining which medications are available to her. The CM also communicates with Ms. K´s family members, and after voicing understanding of her nephew´s reported unease, the CM discussed setting realistic boundaries and expectations because of Ms. K´s condition and difficulty moving around. In efforts to help reach the family member´s goals for Ms. K., her CM has revised the patient-centered specialty practice, which Ms. K. has happily agreed to.

Ms. K´s primary medical doctor is in contract with AgeWell New York and she now receives monthly visits from a nurse practitioner. She receives patient care assistance services seven days a week to assist with activities of daily living and instrumental activities of daily living; ten hours a day for six days and eight hours for one day. Because of her hip fracture and several health conditions, Ms. K requires ongoing patient care assistance for impaired physical/cognitive functioning status. While she is still frail and cannot move around without assistance, Ms. K´s extra hours and attention have helped in assuring that she continues to receive the best assistance for her impaired physical/cognitive functioning status. Ms. K and her nephews are incredibly satisfied with the help they are receiving.