TL is a 36-year-old female that has an IQ of 66 and diagnoses that include autism, anxiety disorder, antisocial personality disorder, and mild intellectual disorder. TL grew up in foster care and has been in and out of group homes and state hospitals from a young age. In 2005, TL was admitted to Madison State Hospital and Sentry Services was appointed TL’s guardian in 2016.
One of Madison State Hospital’s goals is to pursue a discharge plan for each patient. Since 2018, when the current Sentry Services Case Manager became involved, TL has exhibited inappropriate behaviors such as physical aggression, harm toward staff and other patients, selfinjuries, and verbal aggression, which have resulted in her being placed in the quiet room at Madison State Hospital from time-to-time for several hours as well as isolation in her room. While TL has been placed on the discharge list several times since 2018, the Sentry Services Case Manager has never agreed with TL being on the discharge list and has voiced those concerns in hopes of keeping TL and other individuals safe from the harmful behaviors she exhibits.
In September 2021, TL was once again placed on the discharge list. The Sentry Services Case Manager voiced disagreement; this time, noting that TL’s behaviors had increased to an even higher level than in the past. From September 2021 to March 2022, TL had 57 reportable incidents where she caused harm to herself or others, including the staff at Madison State Hospital.
One of the ethical principles of guardianship is to advocate for an individuals’ needs. The Sentry Services Case Manager has never wavered in her belief that TL is in the safest environment possible, not only for her own benefit, but others as well. The Sentry Services Case Manager attended several meetings at Madison State Hospital with TL’s entire care team, as well as a potential community provider, State of Indiana Bureau of Developmental Disabilities Services, to ensure everyone was aware of TL’s behaviors. Each time, the Sentry Services Case Manager had a chance to voice her concerns regarding the discharge of TL and her concerns for the safety of TL and others. Even though the team at Madison State Hospital continues to work with TL to get her to the point where she may someday discharge, as of March 2022 TL was no longer on the discharge list.
The Sentry Services Case Manager continues to advocate on TL’s behalf whenever the discussion of discharge is brought up. The Case Manager is confident that TL would have been discharged and caused harm to herself or others had she not had a guardian to advocate on her behalf. County: Jefferson
Joe is a 75-year-old Medicaid Waiver participant residing in senior housing apartments in Aurora, Indiana. Joe has been diagnosed with A-Fib, Muscle weakness, Diabetes, COPD, Heart Disease, Heart Failure, GERD, Emphysema, Dyspnea, syncope and collapse, weight loss, loss of vision, repeated falls, high blood pressure, amnesia, high cholesterol, insomnia, tremors, and Major depression. Due to these issues and diagnoses, Joe requires assistance with nearly all Activities of Daily Living (ADLs), as well as Medication Management. Joe receives assistance with bathing, dressing, homemaking tasks, and mild meal prep through the use of an Aid for a few hours a few times a week. He receives prepackaged medications from George’s Pharmacy, manages incontinence by using adult diapers, and a walker. Joe’s struggles with his memory and insomnia cause him to be very forgetful to the point of forgetting to eat. He has lost a significant amount of weight, as a result. He receives Home Delivered Meals (HDM) twice daily in addition to Nutritional Supplements. Joe utilizes Catch-A-Ride for transportation, when his friend and main support, Sarah, is unable to give him a ride. Joe has a few friends/acquaintances that have helped him on occasion but does not have any family to provide support.
Joe’s referral came through the ADRC back in June 2019 after a fall left him with a broken leg. At the time, Joe did not have Medicaid, but needed to get to a nursing facility for rehabilitation. The Care Manager at the time, Stephanie Hood, was able to find a Nursing Facility to accept Joe while pending Medicaid approval and coordinated transition back to the community upon discharge in September 2019, as well. One thing that could not be coordinated/obtained prior to discharge was a bed set; however, Joe was able to purchase a blowup mattress to utilize as an alternative.
In January 2022, LifeTime received a grant from Anthem to be utilized on direct client services to combat health disparities relating to the Social Determinants of Health. With Joe being on a fixed income and having no additional funds to purchase items outside of what he considers necessities, the previous Care Manager, Stephanie, checked into Joe’s case to see if he was ever able to obtain a proper bed set. After finding that this was still a need, Stephanie submitted a request on Joe’s behalf for a bedframe, mattress, and box spring. She shopped and purchased all requested items at a local reuse store near her home and solicited two volunteer family members to assist with pickup, delivery, and setup. Joe was so surprised and grateful for the bed and stated, “I will finally be able to sleep at night, and maybe won’t have to nap so much.”
In 2021, Catch-A-Ride transported a legally blind passenger, who we will refer to as Donna, a total of 254 times. Nine of those trips were for various medical appointments and the remaining 245 trips were to/from Donna’s dialysis appointments, which she has three times per week. Catch-A-Ride is her primary means of transportation and it enables her to get to her appointments independently, rather than having to rely on family and friends for transportation. Since Catch-A-Ride is a qualified Medicaid provider and Donna schedules the majority of her trips through Southeastrans, her out-of-pocket cost for all of her 2021 trips combined was only $8.
James is a participant at a Senior Nutrition Activity Center within the Housing Facility where he resides. One day, the SNAC Director noticed that James was not saying much and that he hung around after everyone else had left, so she asked if everything was ok. At first, he did not want to share, but after a while, he revealed that he was going to be evicted from his apartment and did not know what he was going to do. The SNAC Director also learned that James has a son with whom he has little contact, that his driver’s license had expired during COVID, and that he is a Veteran.
The SNAC Director contacted her supervisor and asked for advice. After checking with LifeTime’s Business and Housing Director, the supervisor learned that there is a lengthy process to go through to evict someone and it did not sound as though the housing facility had gone through that process. The supervisor relayed this information back to the SNAC Director, along with phone numbers obtained from the ADRC for Veteran’s assistance.
The SNAC Director gave James all of the information she had gathered. James had also become good friends with another SNAC participant, who was helping him look for another apartment, working with him to get his driver’s license back, and giving him rides, in the meantime. Although we do not have full details as to why, the housing facility decided not to evict James after all.
The SNAC Director’s attentive and proactive behavior allowed LifeTime to work together as a team to gather and provide information as well as monitor the situation, while also allowing James to remain resourceful and handle as much as possible on his own, boosting his self-confidence.
The case presented is a 47-year-old male who has been diagnosed with Melanoma and a mast cell blastoma in the temporal lobe of his brain. He requires total care and is bed bound. The individual is returning home with Hospice care, after having the mast cell blastoma excised. Post-op, the individual experienced a stroke and several seizures that caused severe neuromuscular deficits and weakness. His family is able to care for the individual’s needs but was faced with financial constraints. LifeTime Resources Home and Community Care Division was able to assess the individual and develop a service plan, utilizing Medicaid Waiver to provide Structured Family Care so that the family can be paid a per diem rate to provide his care and will not have to worry about finances while they care for him during his final days. Inpatient acute hospitalization or Long-Term Nursing Facility placement would have been needed to provide for his care if the family had been unable to provide for his care.
Catch-A-Ride's public tranportation service currently tranports a married couple, age 85 and 82, who live in Madison. They are both in wheelchairs and are no longer able to drive. They have been with Catch-A-Ride since 2017. We have transported each of them over 500 times in the past 4 years and our service has allowed them to continue to reside in their home and remain independent. Catch-A-Ride is fulfilling its mission of “working together to provide services that help people maintain their independence” by providing this couple with transportation for a variety of purposes including receiving the Covid Vaccine, health/beauty appointments, doctors’ appointments, shopping, recreation/social activities, personal business, employment, and dining. They are always very appreciative of the service Catch-A-Ride provides and they complement our customer service representatives and drivers on their helpful, friendly attitudes.
SD is a 72-year-old woman who has resided at The Waters of Clifty Falls since July 2017. Sentry Services was appointed SD’s guardian June 29, 2018. Due to SD’s family living in Alaska, they could not be effective at advocating successfully for SD from such a long distance.
In October 2019, the Sentry Services Case Manager (SSCM) was told per the NF Nurse Practitioner, that SD needed to have a bone density test due to her osteoarthritis and a mammogram due to family history of breast cancer. SD was a little apprehensive but agreed to the test if the SSCM would stay with her throughout all of the testing. On December 5, 2019, SD had both the bone density test and the mammogram completed.
The bone density test came back fine but due to some spots being found on SD right breast the mammogram led to the need for an ultrasound. The ultrasound showed a lump, and a biopsy was ordered. The biopsy was completed on December 16, 2019, with findings of an Invasive ductal carcinoma, (grade 1). SD saw a surgeon on January 14, 2020, who recommended a lumpectomy with radiation treatments, if SD was found to be a candidate for this type of treatment. If not, a mastectomy would be the best option for her.
On January 21, 2020, SD saw the oncologist who reported the pathology report showed SD had Stage 1A breast cancer, which is driven by estrogen. He stated this is curable and was caught in the early stages. His recommendation was for SD to have a lumpectomy with Sentinel lymph node removal and then a medication regimen to decrease her estrogen level and annual mammograms. The oncologist stated for women over 60, radiation could be omitted due a 90 % chance this type of cancer not coming back and if it were to come back, it would be at least 10 years. On January 29, 2020, SD saw the surgeon again and based on her breast exam, the surgeon felt the lumpectomy with Sentinel lymph node removal would be the best option for her. Without the requested procedure to treat the diagnosis of cancer, this could spread and cause further medical issues. After pre-surgery tests were completed and SD’s primary care physician could not identify any acute illness or conditions that could require timely interventions and treated promptly to maintain her health and clinical stability, the decision was made for her to go through with the surgery.
Surgery was completed on February 13, 2020. The surgeon was able to remove the lump and after the pathology report was completed, SD was told she is cancer free.
During the whole process, the SSCM attended all the appointments, tests, and hospital surgery. The SSCM also kept SD’s family informed of the outcomes.
SD has had several follow ups since her surgery, her last mammogram was in March of this year, and she saw the surgeon on April 27, 2021. At this appointment SD was given a clean bill of health and does not have to go back until next year after she has her annual mammogram.
The Aging and Disability Resource Center (ADRC) received an e-mail from a LifeTime Resources employee asking if we have ever heard of a particular medical equipment company and wondering if her 78-year-old family member, Joe Smith, was a victim of Medicare fraud. As the contact person for the agency’s Senior Medicare Patrol (SMP), the I&A Supervisor, Diana, reached out to Joe to discuss the details of the case and report findings to the officials, as appropriate.
Diana called Joe the same day to get more information and find out what happened in regards to him receiving a back brace in the mail. Joe reported that he received a call from a medical equipment company about two weeks prior and they asked him if he had arthritis and he said, “yes”. Then, they asked Joe where his arthritis was located, to which he responded, “back”. The medical equipment company asked if they could send Joe a back brace and Joe said “no,” he didn’t want a back brace. The next thing Joe knew, he was receiving a back brace in the mail 2 weeks after the phone call. Joe said he did not give the caller his Medicare number, social security number, or any other personal information. Joe’s wife said the package came with 6 pages of packing lists and included an order confirmation sheet, Rights and Responsibilities, Return Policy, etc. Diana advised Joe and his wife that LifeTime Resources would report the details to the state’s SMP and to be on the lookout for a call from them in the near future. Additionally, Joe and Diana discussed a few tips for avoiding scams in the future, such as screening phone calls that are not from a recognizable number.
Diana called the SMP Program Director the same day and gave her Joe’s name and phone number. The Program Director said she would take it from there and thanked us for reporting it. The SMP Program Director called Joe the very next day to investigate what happened. It turned out that the medical equipment company billed Medicare $1,375 for the back brace and Medicare paid $983 to the medical equipment company. Medicare is issuing Joe a new Medicare card to prevent this from happening again, and SMP will report this to the Administration for Community Living and the Department of Justice for the claim for the back brace to be rectified.
Emily is 86 years old, living in her own home in the Dillsboro area. For the past year or so she has been a regular participant at the Senior Nutrition Activity Center (SNAC) at Dillsboro Village Apartments, but also wanted to find a safe way to get some exercise. She was in luck, as the property manager at Dillsboro Village Apartments manages the Walk With Ease program.
Although the most recent program had ended, there were several individuals that wanted to keep walking and had formed a walking group. The Property Manager urged Emily to join. Emily decided that she would and joined the Property Manager and a few others for a walk a few times per week. At first, Emily could only walk 10 minutes at a time, but was making progress when the Covid-19 pandemic hit. Group walks were canceled for the foreseeable future but that didn’t break Emily’s stride. During the pandemic, Emily and her granddaughter would go to the Dillsboro Park and walk around the trail, which allowed Emily to build up her strength and stamina to the point where she could walk a full mile!
This past fall, we were able to have a socially distanced Arthritis Foundation Walk With Ease Program outside at Dillsboro Village Apartments. The Walk with Ease program allows people who suffer from arthritis and other ailments an opportunity to be active and learn techniques that may decrease pain and stiffness brought on by arthritis and other chronic ailments. Emily was able to participate in the program and continues to remain actively involved with the walking group outside of the program when possible. She is proud of her accomplishments and hopes to remain independent longer as a result of her efforts.
Jane Smith is a 76-year-old female resident of Switzerland County that was negatively impacted by the Coronavirus pandemic when she was left without easy access to food. Jane has High Blood Pressure and Type II Diabetes and can become weak and dizzy at times. Jane lives in a small town with only one grocery store. The National Health Crisis had a huge impact on the town’s local grocery store, public transportation, and SNAC (congregate meal) program that closed at the beginning of quarantine.
Jane has been a client of Lifetime for 3+ years and utilized SNAC and CAR on a monthly basis before the National Health Crisis. Jane was left without transportation to and from the grocery store, to medical appointments, and was no longer able to use the SNAC site as a resource for a warm meal and socialization. Prior to the closings, Jane had a strict routine of visiting the local grocery store once a week for supplies. Jane does not have any informal supports except her friends from the SNAC program. LifeTime was able to provide temporary Home Delivered Meals and partner with the local school corporation for grocery delivery to residents of Switzerland County, including Jane. Two of LifeTime’s staff members volunteered to deliver these groceries to Jane’s home. Additionally, Jane’s Home Care Manager was able to find a local volunteer that could transport her to her monthly medical appointment, which she has used for two months now. Now that transportation is back up and running, Jane is back to enjoying her weekly outings again, and getting to and from the grocery store. Jane is grateful for the coordination offered by LifeTime during the National Health Crisis.
The Bread of Life is the only soup kitchen in Decatur County. They serve meals three days per week to those in need in the Greensburg area. Catch-A-Ride was contacted by the Bread of Life regarding roundtrip transportation for a gentlemen (Adam) who lives in Westport. Adam needed roundtrip transportation to/from the Bread of Life on Monday, Wednesday, and Thursday. Unfortunately, Adam’s ride times conflicted with the many rides Catch-A-Ride regularly provides for Developmental Services Inc. (DSI) consumers in the afternoons.
Catch-A-Ride began working to see if there was a way to help the Bread of Life deliver meals to Adam. After reaching out to INDOT to see if they would allow any flexibility for service coordination during this pandemic, we were happy to learn that INDOT and the FTA agreed to special approval for the public transportation systems in the state to deliver food and/or prescriptions to those in need; services that would normally not be allowed.
In order for meal delivery to work, the meal had to be delivered to Adam within two hours after it was picked up from Bread of Life. We have been able to arrange for the Catch-A-Ride driver to go to the Bread of Life approximately 15 minutes before they open to the public, pick up the meal for Adam, then go to DSI to pick up the passengers there. In less than one hour, while in Westport dropping off a passenger from DSI, the driver delivers the meal to Adam.
Catch-A-Ride began delivering meals to Adam at the end of July and currently has trips scheduled through September 30th. Catch-A-Ride and the Bread of Life, through their partnership, were able to get Adam the meals he needs.
George is a 49 year old male that has been a client of Sentry Services since December of 2006. George lives in a supported living home in Madison with two roommates. George has a variety of health and mental conditions, including Intellectual Disabilities (MRDD), Autism, Impulse Control Disorder, Psychosis, GERD, depression, anemia, and incontinence. His mental diagnoses prevents him from being able to live on his own or make informed decisions about his overall health and wellbeing. George is non-verbal, so his wants and needs are anticipated by his home care staff. George needs assistance and verbal prompts to complete all activities of daily living and receives twenty four hour care, seven days a week.
In late August 2019, George was admitted to King’s Daughters’ Hospital in Madison where he was diagnosed with pneumonia. George’s overall health quickly deteriorated and he soon started aspirating, which lead to the need for a feeding tube. Due to the high amounts of antibiotics George was receiving intravenously to treat the pneumonia, his kidneys started shutting down and he had to go on dialysis. The medical team could not say for sure if George would have to remain on dialysis the rest of his life and, due to his mental capacity, George would not have been a candidate to receive dialysis on an out-patient bases, so his overall quality of life would drastically change. George was transferred from King’s Daughters’ Hospital to Baptist East in New Albany where he could continue to receive dialysis in house for the time being.
While at Baptist East, George’s kidney function, oxygen level, creatinine levels and overall health declined, a feeding tube was placed, and at the time his prognosis was not good. The staff at New Albany stated to the Sentry Service Case Manager that he likely would be on dialysis for the rest of his life and that his overall quality of life would drastically decline. This was a huge change from the client’s life just a few weeks prior. The Sentry Services Case Manager spoke with the Kidney Specialist on staff, due to George’s age and kidney’s not being permanently damaged at this time, the decision was made by the Sentry Service Case Manager to give him two weeks before a final decision would be made on what the next step should be. Surprisingly enough, during that two week span, George was able to go off of dialysis completely, but needed to go to a skilled nursing facility to recuperate.
On September 30, 2019, George admitted to a skilled nursing facility in Seymour, Indiana. George would have to remain there until he was able to get back to and maintain his normal weight, which took about three months. George progressed to where he was able to eat solid foods and his feeding tube was removed on December 27th. George discharged back to the supported living home in Madison on December 30, 2019. Staff reported he is doing very well and happy to be home. George was also able to go back to the day program located in North Vernon, and is participating in community outings with staff and peers.
Had Sentry Services not been there for George, there would have been no one to advocate for him and make his healthcare decisions and he may not be here today.
The amount of staff time needed to resolve the issue or set up the plan: 221 units or 55.25 hours.
Nathalie, Community Care Counselor (CCC), met with Anna (mid 80s) at her home after she called in requesting information on a Personal Emergency Response System (PERS). Nathalie had previously assisted Anna when she was caring for her late husband, so she was familiar with LifeTime Resources.
Anna lives by herself out in the county and is blessed to have some support from her family. She is diagnosed with Arthritis and back/spine problems and has had 3 joint replacements and several back surgeries. Her condition has progressed so that surgical intervention is no longer an option. She walks with her rollator and/or cane and through the years she and her late husband have made updates such as a step-in shower and a ramp to the home to promote safety. Though her mobility is impaired, Anna is independent and still gets out in the community for business and social activities. Anna mentioned that, since her husband passed, she has had to watch her finances carefully due to a drop in income. During the Initial Assessment, Anna and Nathalie discussed several potential options to combat the issues she had been having managing her finances and Anna indicated that, if she could get the assistance that was explained, she would be able to afford the PERS.
Nathalie and her Case Coordinator, Robin, worked together to ensure Anna received the applications she needed. Over the next 8 weeks Anna got to work and got an A+ on Action Plan completion. She called Nathalie at end of the month to give her an update on her progress and reported that she had been approved for the following programs:
Medicare Savings Program
Paid for her Medicare Part A premium and raised the amount of her Social Security Check. Anna received a 3 month lump sum for the 3 months prior to her application.
Extra Help Program
Helps to pay for her Medicare Part D (prescription) premium and lower her monthly medication costs. Anna reported that the Extra Help had already lowered her monthly medication expenses from $150 to $12.
Helped offset her high electric bill during the winter months. - Personal Emergency Response System (PERS) Anna can pay for her PERS now, without worry, and still has a little “extra” at the end
Anna now has the extra security that a PERS affords her and can summon help at home and in the community, should she need it. She has more peace of mind and so does her family.
Nathalie Stephan, Community Care Counselor, spent 6.5 hours on the referral and Robin Ritchie, Case Coordinator, spent 2.25 hours on the case. There is no ongoing cost to LTR as no funded services are currently being provided.
Angel is 90 years old and started using Catch-A-Ride in January of 2017. Since then, she has taken over 1,000 rides. On August 7, 2019 our driver, Rick Plogsted, picked Angel and a couple of other passengers up from the Senior Nutrition Activity Center (SNAC) to take them home. After his last drop off, Rick had to drive back past Angel’s house on his way to Batesville for his lunch break. He slowed down when passing Angel’s house and saw her sitting on her side entrance step at an angle. Rick immediately stopped the van and backed into Angel’s driveway to get a better view of the situation and found that she was unable to get up.
Angel reported to Rick that, after getting the mail from her mailbox, she could not handle the screen door, her mail and her cane and she had fallen. Rick was able to help her to her feet, get her into the house and offer her a bottle of water as well as grab her some paper towels to clean the blood from a small cut on her finger. Rick stayed with Angel until she was able to calm down and call one of her sons.
Rick reported that Angel lives in a large house, with only a few close neighbors, and that traffic coming from the opposite direction would not have seen her with the house and bushes in the way. Rick was very grateful he was there to help Angel in her time of need.
The next day, Michelle Guidice called Angel to see how she was doing. Angel reported that her son had taken her to the hospital for x-rays, but nothing was broken. Angel had her granddaughter staying with her for a couple of days to make sure she was okay. Angel reported this was the second time she had fallen recently and that she was very grateful that Rick stopped to help her, because she did not know what she would have done if he had not stopped. Michelle was able to add Angel’s son and sister’s contact information to her account in the event of a future emergency. In addition, the family was provided information about all of the other services that LifeTime offers, should Angel need them in the future.
One day this past fall, Brenda Thayer, Nutrition Program Manager, received a call from a woman who lived out of state and was crying. Her parents lived locally and she was afraid that they were not eating enough and that their health was in jeopardy. Her mom was having memory issues and her dad didn’t cook much. She asked about Meals on Wheels. When the daughter stated that her parents still drove and were able to get out of the house on a regular basis, Brenda explained they wouldn’t qualify for that program but maybe they would be interested in attending the local Senior Nutrition Activity Center (SNAC).
After Brenda explained that the SNAC was a place for those 60 and over to meet Monday – Friday for a nutritious meal, activities, and socialization, the daughter thought it was a great idea. Then the daughter asked how to go about getting them to attend. Brenda told the daughter that she (the daughter) could talk to her parents about attending or the SNAC Director could call them. The daughter felt her parents might get upset with her, so she asked if the SNAC Director could give them a call. When the daughter gave Brenda her parents’ names and phone number, Brenda realized she had gone to school with the daughter and knew who her parents were and where they lived! The daughter asked if Brenda could keep in touch with her.
Brenda asked the SNAC Director to call the couple and invite them to the SNAC. She called a few times and offered to drop a menu off to them, but they were not receptive to the idea. Brenda then talked to the daughter about an idea she had. Brenda goes to church with a very kind, loving lady that is a neighbor to the couple. She asked the lady if she would be willing to talk to the couple about the SNAC, take them a menu, and attend the SNAC with them if they would agree to go. The lady said yes and that she visits with them on a regular basis. After a couple of weeks, the lady told Brenda she made the visit but she wasn’t sure they wanted to attend. Later that week, the husband stopped at the SNAC and signed up for them to attend 2 times the next week!
When they attended, they realized they knew a lot of the other individuals at the SNAC. In fact, the SNAC Director reported that one day the couple and another participant stayed for at least an hour after everyone else had left, just sitting and visiting! The daughter was over joyed to hear how well it was going.
The couple has been attending since November and it appears they will continue. It took extra effort and thinking creatively, but this “person centered” approach was worth it.