In addition to providing concrete information and system navigation, Social Work staff at Sage also assess clients for elder abuse, social isolation, and problematic hoarding behaviors; help secure financial assistance and benefits; coordinate warm referrals to community resources, and work towards achieving client-identified goals.

Peng came in to see a Sage Social Worker due to issues with accessing transportation. The Social Worker became concerned for her health and took her upstairs to see a Nurse Practitioner. An assessment revealed poorly controlled diabetes, open foot wounds, bed bugs, and a likely hoarding disorder, as well as various issues with other social determinants of health.

She had a broken well in her rental mobile home, and therefore had no access to running water. Because of her hoarding issues, she was unable to approach her landlord about the water. Home care had raised concerns regarding the hoarding, bed bugs, and lack of running water, but were no longer involved. The senior had no transportation, lived outside of city limits, and had to walk 5 km to the nearest bus stop.

Our Nurse Practitioner referred her to Sage’s hoarding program, and to an external diabetic wound clinic as well. The Nurse Practitioner called to coordinate wound care and home care, and the hoarding program contacted Peng to arrange follow up. They also attempted to conduct a home visit with staff from Sage’s hoarding program, but she is currently not willing to proceed with our team’s involvement. The team will continue to monitor the situation and offer assistance when she is ready to proceed.