Lily is a 72-year-old female living in Ripley county. She attends the Senior Nutrition and Activity Center 5 days per week to eat a meal, socialize with others her age and participate in crafts, cards and other activities. In August of 2023 a program was started for the Senior Nutrition and Activities Centers called Produce for Better Health. This program provides 7 to 8 pounds of fresh fruits and vegetables bi-weekly to each participant that signs up for the program and agrees to have their weight and Blood Pressure monitored monthly for the duration of the grant funded program. Lily has participated in the program since it started in August 2023 and has shown improvement in her weight and Blood Pressures since starting to incorporate more fruits and vegetables in her diet. Lily reports that because of the lunches that she eats at the Center and the produce received bi-weekly her monthly food budget is lower, she is eating healthier and isn’t buying as much “junk” food as she had been buying. She is happy to have more healthy choices and enjoys the Nutrition education that she receives every month. Lily, and all Produce for Better Health participants, receive 2 recipes in each bag of produce that utilizes the produce included in the bag. Lily reports that she is excited to see what kind of recipe is going to be included and trying them to see if she likes them. Lily reports that she and the other participants talk about how they are preparing the produce and share recipes of their own and/or how they have tweaked the recipes provided to meet their own tastes. Lily reports that she is trying food that she would never have bought for herself due to cost and not knowing how to prepare it, and that this program has opened her up to trying new things and stepping out of her comfort zone as far as food preparation and trying different foods is concerned.
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.
SR was born on August 10, 1958, in Bartholomew County. SR's dad passed away in 1980 and his mother in 1990. SR had 5 brothers and 4 sisters. According to Sentry Services records, SR's mother was very active in his care until she passed away. At that time, a referral was made to Sentry Services. However, two of SR's sisters agreed to be his advocate and SR moved from MSH to a group home in Dupont Indiana. Sentry Services was contacted in 2005 when SR's two sisters stopped contacting him and would not respond when ResCare staff reached out to them. Sentry Services was able to reach one sister who had moved to Florida and felt she was too far away. The other sister never made contact back to Sentry Services after several attempts were made. Sentry Services was granted guardianship over SR in 2005.
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.
A driver was dropping Ethel, who is blind, at home, when Ethel realized that she did not have her keys with her to get into the house. The driver asked if he could call someone, but her husband works far away so he could not come to let her in. The driver offered to take her to a neighbor to wait for her husband to get home, but when they arrived at the neighbor's house there was no one home there either. So, she asked him to take her back home and told him she would figure out a way to get into her house. After arriving back at her house, the driver called his supervisor for suggestions on what to do to help her.
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 an 86-year-old female who lived on her own in an apartment in Osgood. ZS’s landlord found her walking around the apartment complex completely naked. Upon landlord inspection of ZS’ apartment, ZS was found on the floor, surrounded by medication. At that time, ZS was transported to Margaret Mary Hospital. While at Margaret Mary, she made suicidal statements, therefore, she was transferred to Harsha Behavioral Center where she stayed for 3 months. Due to her declining health, her inability to follow instructions while at the nursing facility, and ZS’s reports of unfounded elder abuse and exploitation, she could no longer continue to live on her own. ZS’ diagnoses include Type II Diabetes, Brief Psychotic Disorder, Major Depressive Disorder, Alzheimer's Disease with Late Onset, Dementia, Macular Degeneration and Significant Hearing Loss.
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.
Arthur began his journey with Lifetime Resources in June of 2022, starting out on CHOICE, non-waiver funding, as he did not yet meet Waiver Level of Care (LOC). Arthur’s primary diagnoses include COPD, hypertension, osteoarthritis, and acute respiratory failure. Arthur was set up with 3 hours of Homemaking per week to assist with upkeep of the home, a Personal Response System (PERS) unit to monitor frequent falls, and Case Management (CMGT) to oversee services and ongoing needs.
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.
In 2022, Catch-A-Ride transported a passenger who uses a mobility device, who we will refer to as Charles, a total of 208 times. His trips were to/from Charles’s dialysis appointments, which he had three times per week until his passing at the beginning of November. Catch-A-Ride was his primary means of transportation and it enabled him to get to his appointments independently, rather than having to rely on family and friends for transportation. Since Catch- A-Ride is public transportation with a low fare rate, Charles only paid $208.00 for his 208 rides in 2022.
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.”
Robert is a very independent individual; he has never been married, has no children, and has no relatives involved in his life. He has been attending the SNAC for several years and those individuals have become his family. Robert enjoys the SNAC and loves to debate with anyone that is up to the challenge.
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.
JK, age 70, a guardianship client of Sentry Services since early 2019, was admitted to Madison State Hospital in 2018. JK’s sister had previously cared for him for years but was no longer able to manage his declining mental health. JK was found to be a danger to himself and others, so he was placed at Madison State Hospital.
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.
Catch-A-Ride partners with three sheltered workshop facilities in our six-county service area. We provide transportation to the facilities for job skills training or to places of employment in the community. From January 1st through June 30th, 2022, Catch-A-Ride transported a 52-year-old African American female passenger with a disability, who we will refer to as Beth, a total of 178 times to/from Beth’s home in Ohio County to her job at Kroger in Dearborn County; generally, four days per week. Catch-A-Ride is her primary means of transportation to her place of employment, enabling her to get to work independently, rather than having to rely on family and friends for transportation. Beth qualifies for funding that the sheltered workshop has available, so Catch-A-Ride bills the sheltered workshop for Beth’s rides on a monthly basis. This means that there is no out-of-pocket cost to Beth and Catch-A-Ride is able to utilize the revenue for match as well. Beth’s ability to get to work regularly has allowed her to remain an active member of her community.
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.