National Social Work Month: Sage’s Client Story of Compassion and Action

March is National Social Work Month, the perfect opportunity to honor the essential role of social workers in eldercare. At Sage Eldercare Solutions, we couldn’t be prouder of our Licensed Clinical Social Workers (LCSWs) and their work in creating wise solutions and enhancing the holistic well-being of our beloved clients.

This blog highlights a client story that reflects the Social Work Month 2025 theme: Compassion + Action. Our featured social worker, Mary Collins, exemplifies “Compassion” and sparks “Action” to enhance her client’s quality of life. You’ll see the theme come to life below.

Social Worker Spotlight: Mary Collins

For over 25 years, Mary Collins, LCSW, has served as a clinical social worker for older adults and their families. She is committed to providing services, support, and interpersonal connections that empower elders to maintain their highest level of independence and quality of life. Mary has been a proud member of the Sage team for 14 years. In addition to her role as a Care Manager, she provides clinical training and support to her Sage colleagues as a Care Manager Mentor.

Mary’s Background in Community-Based Senior Services

Before joining Sage, Mary worked at a community-based geriatric medical clinic providing long-term care management for at-risk seniors in San Francisco’s Tenderloin neighborhood. She also worked at the Department of Aging and Adult Services in San Francisco, where she implemented a specialized care management program for seniors through the Public Guardian’s office. Additionally, she served as an elder abuse investigator with Adult Protective Services.

Mary is well-versed in elder abuse issues, crisis intervention, conservatorships, and caregiver training and supervision. She also understands dementia-related concerns, end-of-life matters, and the medical and mental health challenges faced by seniors.

Client Story: Meet Essie

Recently, Mary worked with an 84-year-old Sage client named Essie (whose name has been changed to protect confidentiality). Essie has lived alone in her one-story, two-bedroom home for 40 years. Mary visited Essie at home to better understand who she is and her current care needs, wishes, and long-term care needs. The assessment enabled Mary to develop a comprehensive plan to meet Essie’s needs while promoting her independence and quality of life.

Initial Assessment

When Mary first visited Essie at home, she identified several key concerns.

The first was Essie’s environment. Her home needed a deep cleaning and some maintenance to address the required outdoor repairs. Despite this, Essie expressed a strong preference to remain in her home.

Secondly, Mary also discovered that Essie had several medical issues and had not gone for regular check-ups since her physician retired a few years previously. Essie reported a history of high blood pressure and had been experiencing worsening vision over the past few years. She also noted a decline in her energy levels. At that time, Essie was not taking any medication, but she had been recently hospitalized after a fall. She had tripped and fallen on the sidewalk, resulting in stitches in her head and skin tears on her arms.

Next, Mary asked about the support Essie receives from her family. Essie’s son is her Power of Attorney (POA), but he lives out of state. Although they talk weekly, he has not visited her recently. At the time, Essie managed her own affairs, but her son had assisted her in setting up auto payments for her accounts and monitored her banking activities.

Lastly, and core to Sage’s approach, Mary asked questions to assess Essie’s quality of life. Essie mentioned that she used to go for daily walks, but since her fall and worsening vision, she no longer felt comfortable going out. Since she no longer drives, her neighbor takes her to the grocery store weekly. Essie no longer attends church, the library, or her women’s group unless someone offers to drive her; these activities used to be a regular part of her life. She reported feeling increasingly socially isolated.

Sage Solutions – The Action Plan

Mary reports that, overall, “Essie was receptive to having someone guide and partner with her on a plan to address her concerns, help her to navigate the medical system, and also help make her son more aware of the changes she was experiencing.” Mary developed and implemented a detailed and comprehensive action plan to address Essie’s needs, including:

1. Collaborated with Essie’s son to understand her financial resources for long-term care.
2. Consulted with collateral support to identify additional areas of need and support
3. Determined if Essie has an assigned primary medical provider and established care with the provider and/or medical group.
   • Scheduled a physical examination for Essie with a healthcare provider, preferably a geriatrician. The appointment should include lab work and referrals to specialists, such as an ophthalmologist, to evaluate her worsening vision.
   • Evaluated the necessity of medications and, if necessary, collaborated with Essie to ensure she took them daily.
   • Requested a referral for physical therapy to evaluate Essie’s gait and balance and determine if assistive devices would be beneficial when walking in and out of the home.
   • Ensured the medical group had Essie’s son’s contact information and copies of her advanced healthcare directives.

4. Collaborated with Essie and her son to address home repairs and schedule a deep cleaning of her house. Scheduled a home safety evaluation and applied the recommendations to enhance Essie’s safety and independence in her home. Mary’s recommended a life alert system suitable for use inside and outside the house.

5. Made referrals to low-vision programs, services, and resources. 

6. Worked with Essie and her son to establish ways to help improve her holistic quality of life.

• • Hired a care provider to assist Essie with groceries, accompany her on walks, do errands, maintain the home, and take her to social events at her church.
  • Contacted her church community to coordinate rides to church and arrange visits from church members and clergy at Essie’s home.
  • Determined if the local library offers services for seniors and investigated their book resources for the visually impaired.
  • Continuously monitored Essie’s quality of care and quality of life and provided her son with a monthly report.

Outcomes

Sage’s action plan addressed the issues revealed by the assessment, delivering the optimal treatment plan for Essie to enable her to stay independent, safe, and as well as possible in her own home.

Medical Treatment

Essie obtained a new primary medical provider (PMP) through her medical group, offering geriatrician consultations. The geriatrician collaborated with her PMP to develop a plan that addressed her medical needs and assessed her care goals. 

Sage involved her son in discussions with the medical team to ensure he understood Essie’s health issues and the interventions she desired and wished to avoid in the future. Essie and her son updated her POLST to reflect her wishes. The updated POLST was provided to Essie’s medical team and displayed in her home.

Essie started on medications for her hypertension. An auto-pill dispenser was purchased, and a monthly nursing visit was provided to fill the dispenser and review Essie’s daily blood pressure readings in her log. Essie’s doctor agreed to order home health physical and occupational therapy. In working with the home health team and local home safety services, Sage ensured that grab bars, raised toilet seats, and a new front railing were installed to increase her safety at home. 

Essie agreed to see an eye specialist to address her changing vision. She got new glasses, and the specialist clarified her concerns about macular degeneration. Low vision services were recommended (Vista Center), and Essie consented to collaborate with her support team to acquire magnifiers and audiobooks she could enjoy. 

Care Plan

Essie agreed to a one-time housekeeping service to clean her home. From then on, she decided to have a care provider three mornings a week to assist with cleaning and maintaining the house, taking her shopping, preparing meals with her, bringing her to church services and events, and enjoying walks and doing recommended PT exercises together. 

Financial Plan

Essie’s son took over all the bill payments, understanding that his mother needed more support in the home to maintain her independence. He continues to have weekly calls with her and a weekly Zoom meeting during one of the care providers’ shifts so they can see each other. 

Safety Plan

Safety systems were implemented in the home, including posting an emergency packet with contact information for her son, doctor, and Sage’s care manager on her refrigerator. Essie also agreed to a Life Alert system that works inside and outside the home. Her team (care manager, care provider, and nurse) monitored her blood pressure and medication compliance and continued to assess the need for other safety equipment in the home. 

Quality of Life

The action plan detailed above produced the desired outcome: Essie’s quality of life was enhanced while she lived independently and safely in her home. indicators of Essie’s improved quality of life:

• Essie and her son continue to have weekly calls and a weekly Zoom meeting during one of the care providers’ shifts so they can see each other.
• Her care provider takes her to social events at her church, including the weekly women’s prayer group, monthly guest speakers, music, and bake sale events, where Essie reconnects with friends.
• Essie gained access to audiobooks through the local library and discussed the books she was reading with her church friends and care provider.
• Essie resumed walking three times a week with her care provider, engaging in her physical therapy routine while listening to music she enjoyed.
• Essie discovered joy in shopping with her care provider and participating in preparing some of her meals as she was no longer cooking alone.
• Essie expressed gratitude, and her outlook reflected a greater contentment with her situation.

About Sage Eldercare Solutions

Mary’s work with Sage clients exemplifies how our team applies expert knowledge and deep compassion to help keep older adults safe, independent, and as well as possible. Visit us here to learn more about our comprehensive eldercare services, including concierge care management, specialized home care, and a unique therapeutic activity program to enhance holistic quality of life. Or feel free to schedule a free consultation to explore how Sage Eldercare Solutions and The Hummingbird Project can provide expert solutions for your eldercare needs.