describe how your recommended referral can help her manage or overcome the stated problem. Include a total of 8 problems with related referrals and explanations.

Care Management Plan Assessment Tool


Read the case study and complete the following assessment tool.


Case Study


Mrs. S is receiving medical treatment for arthritis and diabetes and is overweight. She has problems with her breathing and has difficulty walking, getting into and out of bed, and bathing. You are a care manager for ABC Elderly Care Management. You must review this information, in addition to her existing medical records, so you can make an immediate referral to a new primary care physician. ABC Elderly Care Management also was alerted that Mrs. S may need long-term care.


The new primary care physician met with Mrs. S a few days after receiving her records and performed a comprehensive physical. The physician found that the patient has severe emphysema (for which he orders respiratory therapy) and osteoarthritis. In addition, Mrs. S is taking multiple medications, several of which are unnecessary and will be discontinued. Mrs. S also shows early signs of Alzheimer’s disease.


About a week later, you visited Mrs. S at her home to complete a comprehensive assessment form (CAF). Mrs. S is severely dependent in three activities of daily living and unable to shop or cook for herself. You also are concerned about her eating habits and the fact that she is prone to falling.

Assessment Tool

Research area agencies on aging in your state by using the Internet.

Complete the following assessment tool by identifying a problem and by determining what resources and services you would refer Mrs. S to based on your research. Next, describe how your recommended referral can help her manage or overcome the stated problem. Include a total of 8 problems with related referrals and explanations.

Include references to websites and other sources in the “References” section following the table. Format your assessment tool consistent with APA guidelines.

Identified problem Referral resource or service How referral can help
Example Overweight, poor eating habits


Food preparation and delivery program. Regular delivery of nutritious meals to Mrs. S’s home will ensure that limitations to physical activity do not prevent her from eating a balanced diet.



















Kodner, D. L., & Kyriacou, C. K. (2000, October–December). Fully integrated care for frail elderly: Two American models. International Journal of Integrated Care, 1(1), 1–19.


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