Making A Difference Every Day!

Lily is not a current Home and Community Care client and the only services that she currently receives from Lifetime Resources is Senior Nutrition and Activities Center participation and Produce for Better Health Participation.

Lily lives in a Senior Low-income housing apartment. She has no formal caregivers but she receives assistance from friends and family when she needs it. Lily likes to continue to be as independent as she can and the Senior Nutrition and Activity Center helps her be able to do that.

This writer became the Sentry Services case manager for SR in 2018. In 2018, SR was attending day services at DSI/Sandstone in Madison. SR participated in different activities such as going on outings to the zoo or Hanover baseball games, attending dances, among other things. SR enjoyed working in the workshop at DSI and was proud that he was making his “own” money. SR always asked this writer if his money was safe and if he could carry $10 in his wallet.

Through the years this writer built a relationship with SR that was more than just a working relationship. When this writer would go visit SR, he always smiled when he saw this writer. SR always addressed this writer as Miss. Visits with SR were mostly about the things he had done or wanted to do. This writer discovered that SR enjoyed music, taking rides, and he loved to watch old western shows. Gunsmoke was his favorite. SR enjoyed going out to eat with his housemates. SR's favorites were McDonalds and Kentucky Fried Chicken. SR loved Christmas and always had a big list for Sentry’s Angel Tree program. This writer always tried to find things related to what SR liked. One of the biggest things SR loved was drinking Sprite and eating Three Musketeers candy bars.

In 2020, SR’s health started declining. He started losing weight, and he was diagnosed with COVID- 19/pneumonia several times which led to hospital stays. In 2021, SR was having trouble holding his head up, so a nerve study was completed. SR was diagnosed with Cervical Dystonia, also known as spasmodic torculas. This is where the neck muscles contract involuntarily, causing the head to twist or turn to one side. It can also cause the head to uncontrollably tilt forward or backward. Botox injections were recommended and tried. However, after several injections, no changes were noticed so the injections were stopped. SR was also diagnosed with Polyneuropathy, a simultaneous malfunction of many peripheral nerves throughout the body and multi-focal Vascular disease which affected blood flow to SR's lower limbs. SR lost mobility and eventually needed wheelchair assistance. In early 2022, SR developed a pressure sore on his left foot and wound care started. SR was a diabetic and because of the lack of blood flow to his legs and feet, the sore continued to get worse. Eventually, SR had to have debridement of both feet; his first surgery was in January 2023. After so many treatments with no results, Hospice was called in July 2023 for comfort measures. This writer felt SR would be more comfortable at home, so Norton’s Kings Daughters Hospice started SR’s care. A week later SR had to be transferred to Norton’s Kings Daughters’ Hospital due to the sores on his feet turning black and maggots in his wounds. This writer contacted The Waters of Clifty Falls and SR was transferred there with Amedisys Hospice. This writer made sure SR had his watch and took him his Sprite and Three Musketeers candy bars. SR passed away on August 28, 2023.

Throughout the years this writer was never contacted by any family members of SR and ResCare never reported any family members reaching out to SR. It was discovered by Rodney Nay with Morgan & Nay Funeral Home while researching records for SR's obituary, SR had two brothers and a sister still living in the Columbus area. Attempts were made to contact them with no response. This writer requested SR's obituary be printed in the Columbus paper in hopes his family would see it.

Before SR’s funeral, this writer reached out to her supervisor. This writer wanted to let her supervisor know that SR was to be buried in Columbus and if none of SR’s family showed up and none of the people who cared for SR in his home was going to go to the cemetery, this writer was going to go. This writer couldn’t stand the thought of SR living 65 years on this earth and then being buried alone with no one who cared for him being there.

On the day of the funeral, none of SR's biological family members showed up at the funeral home in Madison. However, SR's family from later in his life was there for him. All of his housemates at the group home were there, all of the ResCare employees that could make it came, and DSI Sandstone sent a bus over with friends of SR who remembered SR from when he attended. Flowers were sent from ResCare, and DSI sent a beautiful windchime in memory of SR. Morgan & Nay had the room decorated beautifully and were playing songs that SR loved to listen to. Morgan & Nay’s Pastor, Caleb Brewster spoke about when Jesus healed a deaf man and immediately his ears were opened, his tongue was released, and he spoke plainly. (Mark 7: 31-37). He related this story to SR and the hard times he had to endure throughout his life, but not anymore. He said with SR's last breath, immediately he was healed from all his illnesses while he lived on this earth. Anyone who wanted to say something was given the opportunity. People remembered SR for his smile, how he loved to talk, how friendly he was to everyone, and how he loved his Sprite and 3 Musketeers candy bars. A DSI staff said she would always remember a time when she fell and SR came over, stuck out his hand and said to her “Take my hand, I’ve got you.” I shared how he was always concerned about his money. This writer took a billfold over to Morgan & Nay that had $0.52 found while packing up his things. This writer had them bury this with SR along with an old watch that didn’t work, but SR loved so much. No one knew how long he had had this or where it came from, but it was the one item SR asked for when being admitted to The Waters of Clifty Falls under Hospice care.

After the service, no one from ResCare was going to the cemetery in Columbus, IN, so when the offer was made by Morgan & Nay, this writer agreed to ride in the hearse with Pastor Caleb Brewster to the cemetery. On this ride, this writer was still hoping when we arrived, a family member would be there. As the hearse pulled up to the gravesite, this writer noticed one gentleman sitting there, who I was told was the grave digger. This writer told Pastor Brewster to go ahead and perform the service as if there were a large crowd, not just three people. Preacher Brewster read the 23rd Psalm and welcomed SR into the gates of heaven.

SR endured a lot while he was on this earth. In the 5 years this writer knew SR, he was always happy, and this writer never heard him complain, until the end, when SR would tell this writer his feet hurt. Hearing this was hard, as there was nothing that could be done. This writer felt SR deserved dignity up to the very last moment, and with the help of the staff at Morgan & Nay, this writer was able to make sure SR was not alone to the end.

He was asked to see if he could help her either get in or call emergency services to get her in the house. Since she was blind, she could have been hurt trying to get in on her own. The driver managed to find a way in through a back door that was unlocked, but had some boxes piled in front of it that needed to be pushed aside and was able to get the client in safely. She was very appreciative of his help.

ZS is able to verbally express her wants and needs. ZS can follow one to two step instructions; however, ZS exhibits occasional delusional thoughts, and can be confused at times. ZS’s cognitive limitations inhibit her ability to care for her health, personal, and financial decisions. ZS is depressed but is not suicidal at this time. ZS was in the locked Dementia unit at the nursing facility due to the possibility of ZS wandering off. ZS has multiple chronic and progressive illnesses which limit her ability to function independently.

ZS was referred to Sentry Services in July 2022 by the long-term nursing facility. The referral was submitted due to ZS’s poor insight, judgement, and wanting to leave the long-term nursing facility to live on her own. In addition, ZS wanted protection from her daughter so that she could not make any decisions on her behalf. This writer spoke to her daughter, and she had no interest in having any contact with ZS, let alone make any decisions on her behalf.

ZS has two sons and a daughter. One son lives locally, but there have been reports of elder abuse, which have since been unfounded. ZS has another son who lives farther away, but also has no interest in decision making for her. ZS had another son who passed away due to suicide, a daughter who passed away due to breast cancer, and another daughter who passed away due to a heart attack. ZS has a strained relationship with her children.

ZS has been married 9 times and is still legally married, however, she has not had contact with her ninth husband in at least 15 years. ZS had expressed multiple times that she just wants to be able to live in her own apartment where she can cook and clean and keep to herself. She feels unsafe in the facility due to the fact that she cannot see very well and cannot hear well even when wearing her hearing aids. If she were in her own apartment, she could lock the door and know that no one would be able to come in.

Sentry Services became her guardian on March 15, 2023. When the writer left the courthouse, she called the Waters of Dillsboro about getting her transferred to a private room on the second floor so that she would feel safe. Miraculously, this move was completed just two days later on March 17. Although ZS felt it was too small for her she was settling in until her health started to decline and has been since moved to the locked Dementia unit at the Waters of Dillsboro. Writer communicates regularly with ZS and with staff to assure that she is comfortable and feels safe.

In February of 2023, Arthur had a severe fall at his apartment while home by himself. Arthur was unable to get himself up and knew he was injured. Luckily, Arthur was able to utilize his PERS unit and press the button to call for EMS assist. Arthur was then taken to the hospital and then to Shady Nook Nursing Facility (NF) for short-term rehabilitation. Arthur and the social worker at Shady Nook remained in contact with Arthur’s Home Care Manager (HCM). Arthur knew that it may not be safe for him to return home alone due to his frequent falls. The social worker contacted his HCM for Arthur to be assessed for Waiver LOC. As a result of Arthur’s decline, he now met Waiver LOC and was assessed to be placed in Assisted Living (AL).

Arthur now resides at Pine Knoll AL, where he is provided with 24/7 care and supervision. He has happily settled into his new home and made friends with several of the residents. Without CHOICE funding, Arthur would not have had the financial means to pay for his PERS unit in order to quickly call for help, nor would he have had CMGT to reassess his LOC and assist with coordination during his care transition to the AL facility.

Catch-A-Ride provides an important service in the community, as demonstrated by this 2022 survey response from a Decatur County resident (name has been changed), “Catch-A-Ride is crucial for Kim in Greensburg to get to and from her new job at Arby's. She has used Catch-A-Ride since it began service in Greensburg. We appreciate the kind drivers and the consistency of service. I have no idea what Kim would do without it.”

During the past year, the SNAC Coordinator noticed that Robert’s health had been declining. In a private conversation, she learned that he wasn’t feeling well, was struggling financially, and didn’t always have much food in his house. She encouraged him to go to the Doctor and contact the ADRC at LifeTime. Robert, being a proud veteran, would not go to the doctor, would not ask for help from anyone or even contact the ADRC.

Food is brought to the housing facility from a local pantry and the SNAC Coordinator encouraged him to at least get one of the boxes of food. He did not want to do that.

After being around Robert for several years, the SNAC Coordinator knew how he was. When the pantry would bring the food, the SNAC Coordinator started getting a few items and slowly giving them to Robert a few at a time. He would accept those from her. The SNAC Coordinator was pleased that he would at least accept a few items. Over time, she was able to slowly increase what she gave him.

While the SNAC Coordinator could not get Robert to call the doctor or the ADRC, she was at least able to make a small difference in his life by being there to talk to him and providing some food for him.

After being appointed JK’s full guardian, among other previously diagnosed mental health issues, JK was diagnosed with anti-social disorder and had a hard time connecting with staff and peers. He also cried a lot for his sister, who would call him periodically. Sentry Services Case Manager visited with JK monthly. At first, JK was very shy and distant. The Sentry Services Case Manager worked with the staff at Madison State Hospital to find out what types of things JK liked and what his interests were and when visiting would talk to JK about these things, which made the visits much more enjoyable for both parties.

In August 2021, the Sentry Services Case Manager attended JK’s team meeting, which is typically with several members of the care team together, so that issues can be discussed and resolved, and was informed that JK’s physical health was declining. He had become almost total care with his activities of daily living, such as needing assistance dressing, putting on his shoes, incontinence, and needing to be in a wheelchair. Because Madison State Hospital is not equipped to care for JK’s physical health and JK had met his discharge criteria pertaining to his mental health, his team reported he would need to be placed in a nursing facility, that was better equipped to handle his care.

Because of JK’s history of people coming into his life and then leaving, the Sentry Services Case Manager wanted to keep JK in LifeTime’s catchment area, to prevent another person no longer being involved in his life. The Case Manager had built a working relationship with the Social Worker at Hanover Nursing Center, who at one time worked at Madison State Hospital and knew JK. The Case Manager reached out to the Social Worker and explained JK’s situation. After assessing JK, Hanover agreed to admit him, and he transferred out of Madison State to Hanover Nursing Center on December 12th, 2021. Since moving to Hanover Nursing Center, JK has made several friends with the staff and one Saturday asked the staff to call the Sentry Services Case Manager. The phone call was brief but, just the thought JK asked to call the Case Manager made it clear that keeping him in our catchment area was the right thing to do.

County: Jefferson

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’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.”

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.