Client Profiles : Mrs. R.'s Story

Mrs. R.'s Story

Mrs. R. is a 72-year old Italian-American woman. Recently referred to One Stop’s care management program by WEME Meals on Wheels, she lives alone, has poor vision and is in marginal health due to debilitating diabetes. In January 2004, she suffered a stroke that left her severely disabled, at-risk, and unable to care for herself.

Mrs. R. does have a daughter and son-in-law, who are able to offer emotional and limited financial support, but not consistent care. Mrs. R.'s family has been instrumental, approving and endorsing all actions suggested by her One Stop worker; they continue to be in regular contact.

Mrs. R. needed a lot of help to stay in her home, including skilled nursing care, homecare, at-home healthcare, and treatment for depression. The One Stop worker referred her to the Visiting Nurse Services of New York’s Mobile Crisis Unit so that she would be seen within 48 hours of the home visit. Mrs. R. was referred to Project Pilot for EISEP homecare, as she is ineligible for Medicaid. The client was also referred to New York Service for Older Persons, SPOP, for in-home psychiatric counseling. We also referred her to the Mt. Sinai Visiting Doctors Program so that she could receive her medical care at home.

The One Stop worker is in constant contact with all the agencies working with Mrs. R. Recently, she has been visiting Mrs. R. in her home twice a week, or more often if needed. She is there to offer supportive counseling while building their relationship and ensuring that Mrs. R.'s needs are being met, and to address any new issues that arise.