OAHR nurses develop individualized care plans (ICP) based on home-based comprehensive geriatric assessment and client/caregiver values and priorities. Developing a care plan is a Medi-Cal Targeted Case Management (TCM) requirement and also a core element of nursing and case management practice. The ICP identifies problems, goals, barriers, and interventions across multiple TCM domains and creates a plan for meeting desired goals within specified time frames. The ICP is ideally developed in collaboration with a client and caregiver and is reviewed every six months and/or at the time of case closure to identify progress and need for adjustment.

The OAHR target population includes low income, medically fragile older adult client 60+ years of age residing anywhere in Alameda County. Clients must have at least one chronic complex medical condition and one functional impairment that puts them at risk for poor health outcomes and out of home placement. 

OAHR provides comprehensive geriatric home-based assessments and sets individualized care plan goals that will help our clients to manage health conditions, improve quality-of-life and/or meaningful life activities, and keep them safely living at home. Nursing care plan goals, and the interventions performed to achieve those goals, aim to: 
1. Optimize access to medical, dental, and behavioral health care services and to improve adherence to treatment plans;
2. Increase effective utilization of home and community-based services and supports. 
3. Improve quality-of-life and/or engagement and meaningful life activities;