RN Case Management Program

With USA’s support, LifeSTEPS has hired a full-time Registered Nurse to act as a Health Care Case Manager (“RN Case Manager”) at three USA properties: Creekside, Sierra Sunrise, and Vintage Oaks. LifeSTEPS’ on-site Directors of Social Services act as lookouts and conduits for seniors needing health care assistance. USA property managers also alert the RN to seniors facing health care challenges.  The RN Case Manager performs a variety of services geared to addressing elder resident needs: assess health care needs; document health care conditions, especially those that are chronic; discuss directly with health care providers the resident’s health conditions and medical needs; advocate for treatment; advocate for those supports necessary for on-going health care conditions (e.g., walkers, wheel chairs, medical treatment for hypertension, diabetes, etc.); and, lastly, follow up with the resident to ensure resolution and/or a clearly articulated and understandable health care plan to manage chronic conditions. This last part is crucial. The key to sustain independent living is the management of chronic health care conditions. Identifying chronic health conditions, obtaining proper medical treatment, and providing the supports necessary to manage chronic issues is the intervention that will allow our seniors to live longer, more vibrant lives.  Residents are noticing how the program positively impacts them: “The program is very beneficial!  My blood pressure was high before, but now it’s under control due to the RN education.  Every time the nurse checks my blood pressure, she is keeping me on track.”  Now in the 3rd year of the program, we are yielding approximately 200 educational and case management outcomes each month.