In This Issue…
- Collaborating on Patient Care: An Interview with Julie Anne Miller
- Assisted Living Project Offers Low-Income Clients New Option
- Buying Peace of Mind - A Follow-up
- HSCN Team in Action: Evelyn Rounds
- A Care Coordinator’s Role in a Skilled Nursing Facility
COLLABORATING ON PATIENT CARE: AN INVERVIEW WITH JULIE ANNE MILLER
Julie Anne Miller, L.C.S.W., Huntington Hospital’s director of Utilization Management, Social Work and Spiritual Care, came to the hospital in 1985 as a social work student intern in both the inpatient hospital and at the newly launched Senior Care Network. Upon graduation she returned to Huntington and for the next nine years provided social work services to hospital patients. In 1995 she left to become a social work administrator at Good Samaritan Hospital in Los Angeles. Five years later she again returned to Huntington and ever since has fostered a close relationship between her department and Huntington Senior Care Network (HSCN).
Perspective: Does your early experience as an HSCN intern impact what you do today?
Julie Anne Miller: My six weeks of being at HSCN and seeing clients gave me a real sense of what Senior Care Network can be capable of, as well as the limitations. Today they help me keep the big picture in perspective. In the hospital we can get a very narrow focus - we have to determine what patients need now. They see a patient more in depth and over time, so it’s a reminder of the full continuum of a patient’s life.
Your staff needs to get patients discharged appropriately and in a timely manner. How does HSCN help?
HSCN staff comes to multidisciplinary rounds and identifies patients who may need services. They have some of the very best deep knowledge of community resources. They know the nuances of what the agencies and services do and who they serve so the right service can be matched to the right need.
What does the interaction mean for HSCN clients?
My staff knows when HSCN clients come into the hospital, so they’re talking to HSCN staff. HSCN has a wealth of psycho-social information about the patient and we put that into our bucket to better know what they will need upon discharge. For example, we can send them to the same agency they are already using instead of a different one. The result is a more satisfactory experience for the patient. We also let HSCN know when we identify patients who are clearly at risk and need case management.
Is it easy for the two departments to work together?
It’s a natural relationship. We have a similar basic philosophy of patient safety, a concern for the whole person and a pragmatic perspective about what is possible. One of the bumps is that the pace of the work is different. It’s been said that HSCN works off a calendar and we work off a stopwatch. We try to give them as much warning as we can when a patient is in immediate need. We know they can’t always get out to the home right away, so we try to build the timing difference into our planning.
A project with patients who have congestive heart failure involves both departments and seems to be going well.
The California Healthcare Foundation (CHF) has funded a project to help these patients better manage their illness when they leave the hospital. We identify and screen patients who might be eligible and then refer them to HSCN for assistance with disease management. The project has been very well received by the cardiologists.
Do you see more collaboration in the future?
The CHF project is a small step, a beginning. I’d like to leverage that. My dream is to partner with HSCN around chronic diseases such as diabetes, congestive heart failure and respiratory disease that benefit from close medical management and care coordination. Patients don’t always have that coordination available to them. There is a tremendous potential for improving the health of the community and continuity of care.
How does the close relationship between the two departments benefit the hospital?
The hospital has an obligation to make sure the needs and care of patients are coordinated across different settings. Patient safety is paramount. We need to ensure that patients get what they need at the right level. In terms of patients, we see what is in front of us, but HSCN gives us a wealth of information that makes for a fuller picture. Overall, it means our patients are better cared for and our community is healthier.
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“Thank you very much for everything. It makes me feel safe with people like you.” – A HSCN client
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ASSISTED LIVING PROJECT OFFERS LOW-INCOME CLIENTS NEW OPTION
Nursing homes are a valuable part of the healthcare continuum, but not everyone who requires long-term care needs to be in one. Until recently, however, many low-income Huntington Senior Care Network (HSCN) clients who were unsafe living at home had little choice.
That’s now changed, according to HSCN director of government programs Eileen Koons, M.S.W., who announced that HSCN has been named a care coordination service provider for the government-sponsored Assisted Living Waiver Pilot Project (ALWPP). Begun in 2006 as a three-year demonstration, ALWPP is testing if assisted living could be an effective alternative to long-term nursing home placement for Medi-Cal recipients.
“We’re very excited about this new option for Medi-Cal eligible seniors and persons with disabilities,” Koons says. “Assisted living is unaffordable for low-income people who need skilled care. We do have programs that support skilled care at home, but they’re not a good fit for everyone. Those with very high safety needs that can’t be met with available resources or who prefer a social setting to isolation at home, for example, now have a broader range of options.”
The project gives eligible individuals a chance to remain in a more home-like environment in the community and grow old in that setting. Assisted living facilities have a 24-hour staff and provide personal care, oversight and other supportive services. ALWPP facilities also offer such services as intermittent skilled nursing care and medication administration in addition to care coordination.
HSCN clinical supervisor Chris Garcia, L.C.S.W. welcomes the new option for HSCN clients. “We see a lot of potential candidates - people who are isolated with no family supports and who struggle to take care of themselves,” she notes. “If you’re sick and you need someone to take care of you, a skilled nursing facility is a good place to be. If you’re not actually ill, don’t need major medical care but do need supervision and assistance, assisted living makes a lot more sense.”
She cites the example of a 90-year-old client living at home alone with no family. “He has some dementia but he’s robust and wants to get out and do things. He’s gotten lost several times and needs guidance and supervision, but he doesn’t need major skilled care. A small board and care facility in a residential neighborhood close to where he lives is ideal.”
Other suitable clients are like the 88-year-old woman who is bedridden and has no family who can help. She had been able to move in and out of bed by herself and with extra help has managed at home. Still mentally alert, her strength has declined recently and she is no longer safe at home. Unable to afford 24-hour help and not wanting to go to an institution, she now has another alternative.
Others who will benefit are those who live in a nursing home but are capable of being in a less restricted setting. Garcia believes that with its expertise, HSCN is especially poised to help people move from nursing homes back into the community. “Our goal is to be a resource for deinstitutionalization,” she says.
Koons predicts that when ALWPP is reviewed by the state legislature in 2009, legislators will see that paying for people to be in an assisted facility is significantly less costly than paying for them to be in a nursing home. In addition, she says, “it gives people a new and better way to be more independent and remain in the community as long as possible.” It’s a sensible response to budget shortfalls, she contends, and is optimistic that the program will continue.
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Fast Fact: HSCN care coordinators made 3,522 home visits in 2007.
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BUYING PEACE OF MIND - A FOLLOW-UP
Lew Farmer, 85, admits he’s a planner. He also values his independence. So 18 years ago when he began to hear about a long-term care insurance product called HomeCare Plus developed by Huntington Senior Care Network (HSCN), he was interested. In those days, public awareness of the emotional burdens and rising costs of extended disability was in its infancy. Most people had never heard of long-term care insurance.
But Farmer had a special reason to be concerned. For nearly 30 years, his wife had been incapacitated by severe rheumatoid arthritis. When their three children were still young, she was already in a wheelchair. Farmer was able to rig up devices to help her manage and modified their house to make it disability-friendly. Juggling his full-time job, he hired students to help with caregiving and household tasks. He joined a support group for caregivers at HSCN and became a facilitator.
Yet behind all his efforts lurked the nagging question of what would happen to his wife if he himself became disabled. “Who would take care of her? I felt I had to do something,” he recalls. So when HSCN introduced its pioneering community-based service/insurance plan, Farmer liked what he heard and was among the first to sign up. (The program is no longer offered.)
Farmer’s wife passed away and he never used the insurance benefits - that is until last year. An active man and a self-proclaimed “doer” who liked to windsurf and sail his Hobie Cat, Farmer was facing a total hip replacement. He called HSCN. “I told them it’s payback time,” he jokes.
A care coordinator came to his home ahead of time to check for safety issues. “She pointed out things I knew but hadn’t done, like removing throw rugs and having handrails in the bathroom,” he admits.
His surgery was successful but Farmer didn’t want to take his children’s suggestion and recuperate in a rehabilitation facility. “I’d go stark raving mad,“ he says. He was pleased to learn that the care coordinator could help him go straight home from the hospital.
Arranging for services that included a live-in caregiver and home-delivered meals, the care coordinator also worked closely with the insurance company. “She set everything up,” he says appreciatively. Several weeks later Farmer felt good enough to be on his own. He continues to receive ongoing monitoring and support.
Has paying for long-term care insurance all these years been worth it? Farmer doesn’t hesitate: “I feel good about it. I didn’t want anyone to take care of me like I had to take care of my wife.”
He has swift advice for anyone on the fence about planning for long-term care. “What are you going to do when you need that? What plans do you have? Do you want your kids to take care of you? I want to stay in my own home.“
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HSCN TEAM IN ACTION: EVELYN ROUNDS
The “Team in Action” series focuses on members of Huntington Senior Care Network’s administrative clinical team and their work on behalf of older adults.
Evelyn Rounds, L.C.S.W. has worked with many people in her social work career, but for her seniors are special. Perhaps it started with being the daughter of older parents. In working with seniors, she says, “I felt I was giving back to them.”
“I have great respect for seniors no matter what the situation is,“ adds Rounds, who is a clinical supervisor with the Multipurpose Senior Services Program (MSSP). “I enjoy the opportunity to sit with people who can give you a snapshot of what your future can be. They have wisdom to share.”
It’s also one reason why Rounds came to HSCN last fall. After helping start up a new MSSP in Riverside County, she left in 2002 to work with other age groups and pursue new endeavors. She realized she missed doing social work and that it was very much a part of her.
Rounds says her return to MSSP has been a great fit. She is again connected to case management, a long-time professional interest. “I enjoy assisting people to accept areas where they need help and making sure they get what they need,” she explains. “If I think there’s something a client can benefit from, I am persistent. I make sure I cover all the arenas before I quit.”
In her supervisory role, Rounds credits patience and a calm, professional approach with helping her assist care coordinators in meeting client needs. “I am good at meeting people where they are and influencing change without being threatening. If I see an area that needs development, I try to come from a factual standpoint. It helps me bring out the best in people.”
She also has a strong interest in social work training issues. She would like to encourage the teaching of social work skills to other disciplines that may work in social services. Such training, she believes, should include an understanding of a client’s right to self-determination and the role of professional boundaries so personal values are not imposed on clients.
Her real passion, however, is the client. “The common denominator seniors possess is being able to stay in their home until the end,” she maintains. “We see situations where a client is pretty much dependent on others for everything and the family is doing their best to keep the client at home. When a program like MSSP can give them encouragement and validation, it is incredibly rewarding to be a part of this.”
Rounds sees plenty of challenges for seniors. Among them are changes in government programs that leave seniors baffled, lack of funding to serve the entire range of seniors affected, and limited resources for the mentally ill, although that has seen recent improvement.
But as she begins to make her own mark at HSCN, Rounds feels she is in the right place. “I enjoy being a part of an environment where the philosophy is to deliver the best care possible. I’m impressed by the level of professionalism here. My goal is to help HSCN go from great to even greater.”
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Fast Fact: HSCN Resource Center specialists responded to 4,199 requests for information and assistance in 2007.
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A CARE COORDINATOR’S ROLE IN A SKILLED NURSING FACILITY
When Huntington Senior Care Network clients enter a skilled nursing facility to live out their lives, the role of the care coordinator usually ends. But care coordinators can still be invaluable “eyes and ears” for long-distance and even local families.
With her mother’s dementia worsening, Mrs. C’s daughter realized that her mother had reached the point where she needed to be in a secure facility with medical care. The daughter, who lived out of state, knew she wouldn’t be able to visit her mother often and asked the care coordinator to stay on and monitor her mother’s care.
Already familiar with Mrs. C and her needs, the care coordinator helped Mrs. C adjust to her new surroundings. He reminded the facility of her medical appointments and kept track of any follow-up. During one visit, the care coordinator saw that Mrs. C wasn’t wearing her glasses and discovered that they were broken. On another occasion her hair was unkempt. Knowing she had her hair done regularly, the care coordinator discovered that her hair appointments hadn’t been scheduled.
Even in the best institutions, tasks can fall between the cracks. The care coordinator has forged good relations with staff, emphasizing that he is there to help, and staff has been receptive. On one occasion when no one was available to take Mrs. C on a recommended outing, the care coordinator arranged for a volunteer to help out.
Mrs. C has been doing well. The care coordinator continues to monitor her health, environment and comfort, report back to the family and follow up as needed. The daughter says she is very grateful to know that a trained professional is there to notice and pursue concerns when she cannot. She says she is more confident that her mother is receiving the best care possible.
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Huntington
Senior Care Network provides access to a complete range
of medical, social and personal services for older and
disabled adults and their families. For more information,
call (626) 397-3110 or (800) 664-4664, visit our Website
at www.seniorcarenetwork.com or
click here to
send us a message
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Perspective is published two times a year by Huntington
Senior Care Network of
Huntington Hospital.
Neena Bixby, M.S.W., L.C.S.W., Director
Gladys Gundrum, M.A., Writer/Editor
