Healthy Aging

Mission:

To improve self-care and independence among our tribal elders, who deserve optimal health and wellness, through coordination of elder services.

Goals:

  • To increase access to services for tribal elders  in the Choctaw Nation
  • To invest in the welfare of tribal elders  for maximum health and independence
  • Assist in the reduction of healthcare cost
  • Maintain functional ability, increased life satisfaction with earlier detection of concerns, and an earlier plan of care

Scope of Services

The Healthy Aging program is a multi-disciplined program providing wellness, social services, behavioral health services, case management, and providers in Geriatric specific care to assist an elder to achieve a higher quality of life or maintain an optimal level of functioning and wellness.

Wellness:

  • Provides exercise programs, nutrition and wellness education to maintain or improve muscle strength, mobility, range of motion, balance, endurance and nutrition education.
  • Conduct biannual fitness and biometric screenings to focus on specific needs and monitor improvement in physical activity and wellness
  • Complete a fall risk assessment through community based physical and fit testing.
  • Provide individual assessment, plan of activity, health education and follow up for continuity of care.
  • Provide follow up on an individual or group basis
  • Schedule periodic encounters at each of the Community Centers in the Choctaw Nation             

Social Services:

  • Assist in finding appropriate support services to meet different levels of care to keep the elder as independent as possible.
  • Research and assist with applications to available services and eligible services.
  • Provide assessment, plan of care and referrals as needed
  • Serve as a liaison with primary care provider, other resources, or programs serving the elderly

Behavioral Health Services:

  • Conduct individual assessments for elders in need of psychosocial issues, safety, and crisis intervention.
  • Arrange/monitor care or services to meet the patients’ needs.
  • Collaborate with the Healthy Aging providers and case managers to assist in the referral process or initiation of a higher level of behavioral health intervention, to include referral for psychological issues.

RN Case Manager:

  • Conduct assessments to identify problems, need for services and eligibility for assistance.
  • Utilize the nursing process directed toward prevention, health maintenance with monitoring/evaluation of the plan of care
  • Complete individual assessments utilizing the Healthy Aging screening tool
  • Develop a plan of care for the elder and family
  • Meet with the patient and family within the elder’s own environment, i.e., home, facility or hospital setting
  • Arrange/monitor home health care services, adaptive equipment, transportation, and any other services needed.
  • Provide crisis management as needed

Geriatricians:

  • Conduct a comprehensive assessment to include:
    • Medical History and Relevant past illnesses
    • Current Medication Regime
    • Cognitive and Physical Conditions; objective assessment of mobility and balance.
    • Home safety and Socialization
    • Disease risk factors, screening status, and health promotion activities
    • Recent and impending life changes
    • Measure of overall personal and social functionality
    • Current and future living environment and its appropriateness to function and
    • prognosis
    • Nutritional status and needs
  • Diagnostic and treatment services for acute/chronic/episodic care
  • Preventive health services and access to screenings for the detection of asymptomatic disease; annual wellness services
  • Collaboration and coordination with primary care providers

Population Served:

The Healthy Aging staff serves elders age 55 years and older with a valid CDIB card.  Case Management Services are also available to non elder high risk patients.

 

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