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