Designing and Implementing Your Program
The Social Worker/Nurse Team
Case management is a core service at Deepdale CARES, with three licensed clinical social workers available to make comprehensive client assessments, develop service plans in partnership with the resident and family members, coordinate services with other agencies, and provide various forms of counseling, advocacy, and benefits assistance.
Equally important is healthcare management. Four days a week, a nurse is on-site at the NORC program, helping to manage chronic health conditions, monitor medication use, provide basic screening, assess the home for safety, and communicate with physicians. Dale Chaikin, RN, has been the community health nurse since the program was launched. Through the Samuel Field Y, the full cost of nursing is included in the Deepdale CARES budget, although Ms. Chaikin remains on the payroll of the North Shore-Long Island Jewish Health System.
But what makes Deepdale CARES truly unique is the close working relationship between the social workers and the nurse. The operative attitude: “It is not my client, or your client, but our client.”
Many initial home visits are made in tandem. True partners, each professional brings a unique set of skills and experience to the visit, but no artificial boundaries divide them. The social worker may engage the client in a discussion about family support while the nurse walks into the bathroom to see whether safety bars have been installed. “Our eyes go to different places,” said Ms. Chaikin. “But we respect each other and understand the importance of approaching every home as a team.”
Seniors seem more willing to open their doors when a nurse and social worker approach together. While many residents are familiar and comfortable with the nursing resource, a social worker’s agenda can seem a bit less transparent, and sometimes raises fears that a resident’s troubles will be “reported” to family members or a doctor. Sending a clear message that the client is in charge also helps to alleviate that fear. “The clients are the ones who dictate how the case goes,” said Ms. Chaikin. “They tell us who we can talk to and who we can’t.”
The Deepdale nurse and social workers also communicate effectively with hospital discharge planners within North Shore-LIJ’s Health System, ensuring a continuum of care. When a resident is being discharged, NORC program staff finds out about it, and learns how long Medicare-funded home care will be in place. “We meet with hospital social workers and home care nurses so that they can update us on the client and we can let them know what our services are,” said Ms. Chaikin. “The hospital is thrilled to know that care will remain in place after a patient is discharged.”
Advocating for Better Transportation
Public transportation options are limited in northeast Queens, especially for residents who can not easily walk to bus stops, or transfer from one bus to another. Resident surveys and comments from Advisory Council members underscored the vital need for better transportation to medical appointments, shopping, and local educational and recreational activities.
One option is Access-a-Ride, a Metropolitan Transit Authority service for New York City residents with disabilities who can not use the public transportation system. With advance reservations, Access-a-Ride will provide shared, door-to-door service 24 hours a day for the usual price of a subway or bus.
There is just one catch: the program operates only within the five boroughs of the city. But Deepdale sits right on the city’s border with Nassau County, and many residents see physicians on the other side of that dividing line.
The residents of Deepdale decided to speak out about the impact on their lives, boarding a bus chartered by the Samuel Field Y to make the three-hour journey to Albany, where they testified in favor of changing the geographical restriction.
“As a professional, I can talk until I’m blue in the face about allowing Access-a-Ride to cross county lines,” said the Y's Karen Schwab. “But when we have a senior who is 85 and stands up before the legislature and says, ‘I can’t get to my doctor any longer because he has moved across the county border and I can’t afford the $25 taxi,’ that has a very different impact.”
Their compelling testimony helped get a bill passed by both houses of the legislature, but it was vetoed by the governor. Assemblyman Mark Weprin, who represents the district that includes Deepdale, intends to introduce a new bill at the next legislative session. Meanwhile, the seniors have learned a lot about what it takes to be heard, an essential skill as they testify in favor of renewing public NORC program funding. Their activism has also helped to raise awareness in the surrounding community about transportation challenges, making it easier to attract donations for other solutions.
For now, the Samuel Field Y is meeting many of the transportation needs of Deepdale residents with a van service funded by New York City’s Department for the Aging. The Deepdale CARES office manager works with the Y’s transportation coordinator to make that happen. Private donations are used to pay for supplementary taxi services, which are available on an as-needed basis.
Social work and nursing staff recognized falls as a serious problem within the Deepdale community. Data from the North Shore University Hospital confirmed that: in 2002, 80% of emergency room visits by people 65 or older living within the Deepdale zip code were due to falls-related injuries.
NORC program staff were already trying to identify risk factors for falls in residents’ homes, but they had no mechanism for communicating with physicians about the problem. The NORC Health Care Linkage Project, funded by the United Hospital Fund and the New York Community Trust to promote closer connections between NORC programs and health care providers, offered an opportunity to take on this issue.
“Our underlying goal was to open up communication between patients and doctors,” said Ms. Schwab of the Samuel Field Y. “We chose falls prevention as the methodology to do that.”
Ms. Chaikin, the Deepdale community nurse, added: “We knew if we could establish relationships with physicians on the subject of falls, it would transfer to other areas and help us manage the client.”
Planning the project
Community partners were involved as the falls prevention project was planned. In particular the North Shore/Long Island Jewish Health System, the health care partner, contributed its expertise through its Geriatric Committee, its Osteoporoses Task Force, and its home care network.
During the planning phase of its falls prevention project, Deepdale CARES staff:
- Screened residents and concluded that almost two-thirds of those responding were at risk for falls.
- Held focus groups with residents, which revealed that they were not routinely assessed for falls by their physicians, and that they generally reported a fall only if they suspected a broken bone. The focus groups also suggested seniors were not being properly trained in the use of assistive devices, such as canes.
- Held focus groups for physicians, who stressed the importance of a streamlined process for communicating with NORC program staff. They were concerned about being overburdened with paperwork and preferred to exchange information via fax.
- Reviewed the tools available to assess risks for falling and concluded that a questionnaire developed by the John A. Hartford Institute for Geriatric Nursing created the fullest portrait of vulnerabilities.
- Identified diagnoses that may entitle patients to receive reimbursable outpatient physical therapy.
Implementing the Project
Building on that information, Deepdale CARES staff implemented a falls prevention protocol that:
- Administered the Hartford Institute Falls Assessment Tool in the homes of 93 residents considered likely to be at risk. Many of these residents were identified by the Deepdale CARES nurse; staff, family members, neighbors, and primary care doctors suggested other potential participants. The in-home assessment allowed staff to evaluate the physical environment at the same time each resident was surveyed.
- Distributed information to community physicians about Deepdale CARES and the falls intervention program.
- Developed a care plan for each resident considered at risk.
- Faxed the assessment results and suggestions for care and referrals to participating physicians.
- Received back the care plan/referral form from physicians, who had an opportunity to request any of the following services for their patients, including: home safety assessments, medication monitoring, blood pressure monitoring, social work evaluations, and referrals or physical therapy and adaptive equipment.
- Provided follow-up to keep residents, physicians, and other service providers current on client progress.
- Conducted community education and distributed materials to help seniors recognize the risk factors for falls and the importance of good communication with physicians. Physicians received magnets with NORC program contact information on it.
- Reassessed participants to determine the program’s impact on their risk for falls and their communication with providers. Continued...