Sheila, is a 72-year-old female with multiple health issues including infected wounds and high fevers. She appears to be confused and disoriented which may impede her getting to necessary medical appointments and understanding any treatment that she may need. As of now she does not have access to reliable transportation. In addition, her adult children have noticed some changes since the passing of Sheila’s husband one month ago. Some of these concerns include Sheila’s deterioration in diet, daily alcohol consumption, smoking and strained relationships with her family. Sheila may be experiencing depression in addition to her confusion and health concerns. My hope is that by collaborating together Sheila can receive all of the benefits she qualifies for and give her optimal care.