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Case Study - Mr. Richard Kaye

Ruby contacted Mr. Kaye and his son Rob to set up a time to begin the service plan prior to Mr. Kaye’s hospital discharge. She asked Rob who else was involved in his father’s care to make sure she invited everybody involved to participate. Rob gave her the phone number of the hospital social worker who was helping with Mr. Kaye’s discharge.

Later that week Ruby sat down with Mr. Kaye, Rob, Rob’s son, and the social worker.  Ruby was very attentive to Mr. Kaye as she moved the conversation through the agency’s needs assessment protocol. She paused often to confirm that the discussion was in line with Mr. Kaye’s needs and wishes.  After a lengthy conversation the group agreed that Mr. Kaye’s needs included:

1) Help with dressing, breakfast and lunch preparation, and bathing 3 times a week
2) Preparation and monitoring of medications
3) Improved strength and balance to prevent falls

In response to the needs identified, Ruby included the following HCBS supports in Mr. Kaye’s plan:

  1. A personal care attendant for 2 hours a day Monday thru Saturday in the morning to assist with meal preparation, dressing, and bathing.
  2. Weekly RN visit to prepare Mr. Kaye’s medications and monitor his blood sugar;
  3. Physical therapy to maintain the progress he made while in the hospital.

She provided the family with a list of available agencies in the area. The family chose one based on a neighbor’s recommendation. Ruby also discussed a back-up plan with the family and they identified a second care worker to fill in when needed. Ruby knew from prior conversations that Mr. Kaye wanted to remain at home so she made a note of that in the file and did not waste his time discussing other options.

The group also discussed a number of services and supports to be provided by the family and other community partners outside of the HCBS program, like Meals on Wheels, but since those were not HCBS services Ruby did not include them in the plan.

She sent the draft plan to Jane for her review.



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