Older Adult Care Planning Assessment

Personal information

Name: Eleanor Vance Date of birth: 14/05/1942 Sex: Female Phone number: (312) 555-0148 Address: 1428 Elmwood Ave, Apt 2B, Oak Park, IL 60302

Emergency contact information

Name: David Vance Relationship: Son Phone number: (312) 555-0192 E-mail: dvance72@email.com

Insurance information

Insurance provider: Medicare / Blue Cross Blue Shield of Illinois (Supplemental) Policy number: 849201749A Group policy number: GRP-44012

Medical information

Primary physician’s name: Dr. Marcus Thorne, MD Phone number: (312) 555-0200

Medical conditions

Mild vascular dementia Osteoarthritis (bilateral knees and hips) Essential hypertension Stage 3a chronic kidney disease (CKD) Presbycusis (bilateral hearing aids)

Medications

amlodipine (Norvasc®) | 5 mg PO | QD donepezil (Aricept®) | 5 mg PO | QHS paracetamol (acetaminophen, Tylenol®) | 500 mg PO | TID PRN pain cholecalciferol (Vitamin D3) | 1,000 IU PO | QD

Allergies

Lisinopril (angioedema) Penicillin (maculopapular rash)

Special dietary needs

Low-sodium diet (< 2,000 mg/day) for HTN. Pre-cut meats required due to reduced hand dexterity from OA. Encourage oral fluid intake (minimum 1.5 L/day).

Personal preferences

Tea/coffee: Decaffeinated Earl Grey tea with a splash of skim milk and 1 tsp honey, served warm at 08:30. Preferred walking location: Paved courtyard pathway behind the apartment building. Favorite activities: Listening to classical music (NPR), large-piece jigsaw puzzles, folding laundry, looking through family photo albums. Other preferences: Prefers to wear cardigans as she feels cold easily; dislikes loud television noises; prefers female caregivers for personal hygiene tasks.

Caregivers Primary Caregiver: David Vance, Son, (312) 555-0192 (lives 15 minutes away, visits 3x/week) Secondary Caregiver: Sarah Vance, Daughter-in-law, (312) 555-0195 Professional Caregiver: Maria Gonzalez, Home Health Aide (Comfort Keepers), (312) 555-0880 (Mon–Fri, 08:00–14:00)

Daily routine

Morning: Wakes at 07:30. Assisted with toileting, morning wash, and dressing by 08:15. Breakfast and morning meds at 08:30. Short walk in the courtyard at 10:00 if weather permits. Afternoon: Lunch at 12:30. Rest period/nap in recliner from 13:30 to 15:00. Light activity (puzzles or music) and afternoon snack at 15:30. Evening: Dinner at 18:00 (prepared ahead by HHA or brought by son). Evening telephone call with son at 19:30. Bedtime hygiene, evening meds, and in bed by 21:00.

Mobility assistance

Front-wheeled walker (FWW): Required for all indoor and outdoor ambulation due to knee OA and unsteady gait. Stand-by assistance (SBA): Needed for sit-to-stand transfers from low surfaces and getting in/out of the shower.

Daily living assistance

Bathing: Moderate assistance required for shower transfers and washing lower extremities; uses shower chair and handheld sprayer. Dressing: Minimal assistance needed for fasteners (buttons, zippers) and putting on socks/shoes. Eating: Independent with eating once meals are prepared and meats are pre-cut. Toileting: Independent during the day with raised toilet seat and grab bars; uses bedside commode at night. Housekeeping: Dependent on HHA and family for all heavy housework, laundry, grocery shopping, and meal preparation.

Other care needs

Medication management: Requires weekly pillbox setup by son and daily verbal prompts from HHA/family to ensure adherence. Hearing aid maintenance: Needs assistance changing batteries weekly and ensuring devices are placed in the drying box at night.

Safety measures

Fall prevention: All throw rugs removed; nightlights installed in bedroom, hallway, and bathroom; grab bars installed in shower and by toilet; non-slip footwear worn at all times. Fire safety: Stovetop knobs removed (uses microwave only with supervision); smoke and carbon monoxide detectors tested monthly by son. Emergency: Wearable personal emergency response system (Life Alert) worn as a pendant at all times; emergency contact list posted on the refrigerator. Other safety measures: Water heater set to maximum 48 °C (120 °F) to prevent scalding; wander guard chime installed on the front door.

Care goals

Short-term goal (3 months): Maintain zero falls in the home environment through consistent use of FWW, home safety modifications, and supervised transfers. Short-term goal (3 months): Achieve 100% medication adherence via weekly pill organizer setup and daily caregiver/family reminders. Long-term goal (12 months): Preserve current baseline functional mobility and ADL independence to allow patient to safely age in place and delay institutional placement.

Services required

Home Health Aide (HHA): 30 hours/week (Mon–Fri, 08:00–14:00) for personal care, meal preparation, light housekeeping, and companionship. Physical Therapy (PT): Home-based PT 2x/week for 6 weeks to focus on lower extremity strengthening, balance training, and safe transfer techniques. Occupational Therapy (OT): Single home visit for further environmental assessment and adaptive equipment recommendations for kitchen tasks.

Additional notes

The patient demonstrates mild short-term memory deficits and occasional word-finding difficulties, but remains pleasant, cooperative, and oriented to person and place. She has strong family support from her son and daughter-in-law, though her son expressed mild caregiver strain balancing his full-time job with evening check-ins. Discussed adult day program options and respite care resources should her cognitive decline progress or nocturnal wandering develop. Next routine care plan review scheduled in 6 months, or sooner if clinical status changes.