Eva,* 53, was referred to the Community Care Transitions Program after receiving treatment at Glendale Adventist Hospital following a fall. She has a number of chronic health conditions including, diabetes, anemia, high blood pressure, degeneration of a lumbar disc, and borderline dementia.
A few days after discharge, Delia, a transitions coach, visited Eva at home to assess her needs and review her medications. During the visit, Delia learned that the lumbar condition is making it extremely difficult for Eva to walk long distances. She suggested that Eva apply for a handicap permit to make it easier for her to park, and provided Eva with the necessary paperwork from the DMV.
Although Eva currently receives in-home supports and services (IHSS), she is worried that her increasing memory loss may mean she will need additional help in the near future. Delia encouraged Eva, and Eva’s daughter, who currently acts as her primary caregiver, to contact her regional IHSS supervisor and raise her concerns. Delia also recommended that Eva seek counseling for her dementia. Eva does not want to pursue counseling currently, but was happy to know such services exist.
“The coach was very helpful in explaining options and services. I am glad to have someone to contact in case I need further assistance.”
* Not client’s real name
