Position Available at New York Foundation for Senior Citizens

New York Foundation for Senior Citizens



Transitional Manager (Registered Nurse Leader of Transition Management Team)


Job Description

When a patient is discharged from the hospital, the transition from the hospital to the community setting is a critical time when many patients are at significant risk for re-hospitalization. This risk may be increased by medical factors (such as complex medication regimens, diseases with high risk of recurrent exacerbations for decompensation, or comorbid behavioral health needs); social factors (such as housing instability or food insecurity); and systems issues (such as incomplete communication of   patient’s inpatient medical information to community providers).


The Transitional Manager (TM) is responsible for proactively coordinating care and assisting with transitioning medically complex patients from the hospital to home. The TM works collaboratively with physicians and nurses in the hospital, primary care providers, care managers in the ambulatory setting and community, home care, and other members of the multidisciplinary care team in order to ensure the transitional needs of patients/families are identified and met. The TM will assess patients to identify risks impeding adherence to medical treatment plans, coordinate with the hospital care teams during the patient's stay, and assist patients and caregivers with the identification of issues/goals/interventions. They will follow-up with patients and caregivers for 30 days post discharge in order to ensure safe transitions of care and help reduce unnecessary hospital readmissions and ER visits. The assessment will take into account the patient and his/her caregiver’s perception of needs in order to make a safe transition from hospital to home.





1.     Receive list of identified high risk admitted patients eligible for care transitions program.

2.     Attends interdisciplinary rounds with the in-patient unit team.

3.     Meet eligible patients soon after admission to initiate engagement and enrollment; collaborate with hospital health care team to review patient status; and ensure processes are in place for patient to have a safe, timely discharge.

4.     Complete assessment of patient to determine what care, services and follow up are needed to ensure a safe discharge and transition from hospital to home. Determine if a home visit is required within 24-48hrs.of discharge.

5.     Reconcile discharge medications and if possible obtain names of medications patient is currently taking at home. The RN Team Leader reviews medications with patient and caregiver and ensure that they understand the indication for use, frequency and dosage.

6.     Assess primary verbal and written language and health literacy to determine best way to communicate health information.

7.     Plan for how exacerbation/decompensation of disease once home will be handled. Make sure Patient and caregiver(s) know who to call if he/she has a problem.

8.     Make sure patient has follow up appointment with Primary Care Physician and other specialists as indicated.

9.     Initiates care plan prior to discharge and revises as needed throughout the 30 day period in collaboration with the patient/family and members of the care team.

10.  Ensure that a phone call is made to patient within 24- 48 hrs. after discharge to ask if patient has filled medications, understands and is taking them,  is aware of signs and symptoms of decompensation, ordered services are in place. 

11.  Coordinate with home health care agency field nurse. If patient is not receiving this service assess if home visit is needed within first 24- 48 hours after discharge for home safety issues, medication concerns, signs and symptoms of disease decompensation or other concerns.

12.  Call patients to remind them about upcoming appointments and follow up after appointments. 

13.  Communicate with health care providers as needed. 

14.  Conducts case conference after critical events such as ER visit, in-patient admission, eviction, etc.

15.  Identify long term care management needs and makes appropriate referrals such as to Health Home, other home and community based services, MLTCP prior to the end of the 30 day period.

16.  Document all encounters in GSI as per protocol.

17.  Direct and supervise other team members such as Community Liaison.

Sad News

It is with sadness that we inform you of the passing of long time SUN-B member George Fehling.
George was a dedicated advocate and consummate professional. He served as a  past board member of Senior Umbrella Network of Brooklyn. He started his business, Ramps/Lifts for Better Living, with a passion for greater accessibility for the handicapped and was actively involved in many community projects. He truly made a difference in the lives that he touched. He will be missed and long remembered.
Details for visitation and funeral are as follows:
Monday, February 22, 2016
 2 - 5 PM
 7 - 9 PM
John Vincent Scalia Home for Funerals
28 Eltingville Blvd
Staten island, NY 10312
Funeral Mass
Tuesday, February 23, 2016
9:45 AM
Saint Clare Church
110 Nelson Ave.
Staten Island, NY 10308

Brooklyn Gardens Nursing and Rehabilitation Center

Announcing our new name, Bishop Henry B. Hucles Nursing Home has officially been sold to the Melnicke Group and effective immediately our name has been changed to Brooklyn Gardens Nursing and Rehabilitation Center.
Web site and e-mail addresses will be changed shortly and the new name will be introduced to the community including our hospital affiliations. 

Submitted by: Robert DeVito

Bulletin Board










The purpose of this email blast is to make you aware of a unique healthcare provider serving Brooklyn and its surrounding areas that has recently become a supporter of our SUN-B organization.  The name of this healthcare provider is SPRI Clinical Trials, LLC. 


SPRI is an independent medical research practice located in Coney Island, Brooklyn that works in collaboration with pharmaceutical companies in the conduct of clinical studies aimed at attempting to establish or confirm the safety and effectiveness of new and more effective medications for the treatment of people suffering from a number of important medical conditions for which there remains a significant unmet medical need. 


Currently, SPRI is evaluating mediations for the potential treatment of the following medical disorders:  Alzheimer’s disease, migraine headache, schizophrenia, depression, bipolar disorder and osteoarthritis. 


Should you have the occasion to work with a client who might be looking for a potentially better alternative to the treatment of one of the disorders listed above,

please consider making them aware of SPRI and what it has to offer.


Ø  Participation in our clinical trials is entirely voluntary and held strictly confidential.

Ø  Study medication and study-related visits, procedures and tests are provided free of charge.

Ø  Limited financial compensation, as well as reimbursement to cover reasonable food and travel-related expenses, may be provided.


The enrollment period, as well as the total number of people that can participate in any given trial, is strictly limited.  So, it may be important for your clients to act quickly in order to take advantage of this important opportunity.


Should any of your clients wish to consider volunteering or learn more about what is involved in participating in one of SPRI’s clinical trials, they can either visit us on the web at www.spribrooklyn.com or call us at (718) 646-2400.


Thank you, in advance, for helping us get the word out to the community we serve about what the potential benefits of participating in a clinical trial can be.



SUN-B Corporate Sponsor

Where Legal Advice is an Art




The Elder Law Minute TM


Powers of Attorney: Trust Your Agent

By Ronald A. Fatoullah, Esq. and Debby Rosenfeld, Esq.


When offering legal advice, one of the first things we recommend to our clients is that they must have a well-drafted power of attorney.  A power of attorney is a document whereby the person signing the power (the “principal”) authorizes another person or persons (the “agent(s)”) to sign and act on his or her behalf with respect to financial matters.  Having a power of attorney is imperative in case an individual should become incapacitated in the future.  At such time, the individual may no longer be able to oversee his own finances, and having appointed an agent to do so will allow for the continuity of asset and income management without interruption.  A power of attorney can also eliminate the need for a court appointed guardian should the principal become completely incapacitated.

When preparing a power of attorney, a great deal of thought must be given to who should be appointed as agent.  The New York State General Obligations Law dictates that the appointed agent has a fiduciary responsibility to the principal. This means that the agent must always have the principal’s best interest at heart and must act in a prudent way that benefits the principal.

Nonetheless, the power of attorney does offer broad powers and an agent is given a large degree of leverage.  When an individual becomes incapacitated, the transfer of such person’s assets might be necessary. Complex planning may be involved in order to preserve the person’s assets.  Accordingly, a carefully drafted power of attorney should be extremely comprehensive, allowing the agent to do extensive planning, if necessary. In appointing an agent, the critical element is one of trust.  If the principal trusts the appointed agent, it is not as important for him to understand the intricacies and nuances of advanced Medicaid planning. He can simply rest assured that since the document contains extensive powers, the appointed agent will be able to act on his behalf, should the need arise.

It is worth mentioning a news story in connection with this discussion.  In 2007, Nicholas DeTommaso, then his in early 80s, appointed Pamela Becker, age 62, as his agent under a power of attorney.  Two years later, Ms. Becker used the power of attorney to arrange for Mr. DeTommaso to legally adopt her. Mr. DeTommaso died one month after the adoption and Ms. Becker took over the lease to his Long Island City apartment for which he was paying $100 a month.  The State Division of Housing and Community Renewal ruled that Ms. Becker was not entitled to the apartment because she only had lived there as a family member for 22 days before Mr. DeTommaso’s death and not the two years required by New York State.  Ms. Becker refused to move out and has been fighting this determination, claiming she is a family member.

This story illustrates how vital it is to appoint a trustworthy party as agent; one who will not use the form to advance and promote his or her own financial interests.  An experienced elder law practitioner will be able to guide you in the preparation of a power of attorney as well as other important legal documents.

Ronald A. Fatoullah, Esq. is the principal of Ronald Fatoullah & Associates, a law firm that concentrates in elder law, estate planning, Medicaid planning, guardianships, estate administration, trusts, wills, and real estate. Debby Rosenfeld, Esq. is a senior staff attorney at the firm. The law firm can be reached at 718-261-1700516-466-4422, or toll free at 1-877-ELDER-LAW or 1-877-ESTATES.  Mr. Fatoullah is also the co-founder of JR Wealth Advisors, LLC. The wealth management firm can be reached at 516-466-3300 or 800-353-3775.




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