Older Adults, Healthy Results

What We Do

Older Adults, Healthy Results provides Public Health Nurse case management to vulnerable, low income Alameda County elders.  We conduct comprehensive assessments in the home and, based on the results, develop individualized care plans that prioritize client safety, goals and values, and medical treatment plan.  In addition to high intensity psychosocial case management, we provide care coordination, health education, client advocacy, healthcare system navigation, and social emotional support to our clients.  We launched 10/24/17 and are piloting an approach that is entirely new to ACPHD.  As a result, we are having to adapt and iterate as we learn and grow.

Who We Serve

OAHR offers case management to eligible Alameda County residents 60 years of age or older.  We work with medically complex patients whose psychosocial challenges interfere with their ability to follow through on treatment plans, achieve optimal quality of life, and ultimately jeopardize their ability to remain living in their homes.  In addition to age 60+, clients must have at least one functional impairment that leads to an Activity of Daily Living (ADL) limitation.  They must also agree to a comprehensive assessment conducted in their home.

How We Impact

We aim to show the following outcomes:    

1. Improved access to medical, dental, and/or behavioral health services and adherence to health-related treatment plans.
2. Improved linkage and effective utilization of home and community-based services so that clients can remain safely living in their homes and communities.
4. Reduced risk of falling.
3. Improved quality-of-life.

What We Do

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.

Who We Serve

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. 

How We Impact

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;

What We Do

See above under Individualized Care Plan (ICP) goals

Who We Serve

See above under Individualized Care Plan (ICP) goals

How We Impact

See above under Individualized Care Plan (ICP) goals

What We Do

See above under Individualized Care Plan (ICP) goals

Who We Serve

See above under Individualized Care Plan (ICP) goals

How We Impact

See above under Individualized Care Plan (ICP) goals

What We Do

OAHR provides home-based nurse case management to medically fragile older adults 60 + throughout Alameda County. We perform comprehensive geriatric assessments in the home including a thorough safety assessment that identifies our clients' risk of falls. The nursing assessment takes multiple factors into account including history of falls, physical, environmental, sensory, medical & pharmaceutical, cognitive, and psychosocial risk factors. If a nursing assessment identifies an increased risk of falling, the nurse develops care plan goals and interventions to address and reduce that risk.  OAHR tracks results of fall risk assessment and the nurse's efforts to implement interventions to address those specific risk factors. 

Who We Serve

See above under Individualized Care Plan (ICP) goals.

How We Impact

OAHR nurse case managers reduce client fall risk by providing interventions to reduce risk such as: referring for home health services, obtaining RX for durable medical equipment, obtaining and/or enhancing caregiving resources, training caregivers and clients around mobility and transfers, performing cognitive and sensory evaluations, linkage to vision services and supports, communicating with and referring to healthcare providers for further workup and evaluation, home modifications, referral for substance use treatment, harm reduction strategies to promote behavior change, etc.