To improve self-care and independence among our tribal elders, who deserve optimal health and wellness, through coordination of elder services.
1. To increase access to services for tribal elders in the Choctaw Nation
2. To invest in the welfare of tribal elders for maximum health and independence
3. Assist in the reduction of healthcare cost
4. 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.
· 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
· 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
· 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
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
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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