Position Available at New York Foundation for Senior Citizens
New York Foundation for Senior Citizens
Transitional Manager (Registered Nurse Leader of Transition Management Team)
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.
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
SUN-B Corporate Sponsor
Where Legal Advice is an Art
The Elder Law Minute TM
Considerations When a Spouse Needs Nursing Home Care
By Ronald A. Fatoullah, Esq. and Stacey Meshnick, Esq.
Nursing home care in the New York Metropolitan area can cost up to $18,000 per month. When one spouse becomes ill and requires nursing home care, the well spouse should seek the proper advice regarding the resulting issues and possible solutions.
When contemplating nursing home admission, a couple should make sure that all of their necessary documentation is in order. If they haven’t already done so, the couple should execute advance directives, namely a Power of Attorney, Health Care Proxy and Living Will. These documents will allow the well spouse and/or the children, if any, to act on the sick spouse’s behalf. If Husband lacks the capacity to execute documents, a guardianship proceeding with a request to engage in Medicaid planning and other financial transactions may be necessary.
If payment options such as long-term care insurance are not available, Medicaid planning may be necessary. If the couple is engaging in Medicaid planning, the well spouse should execute a new will leaving out Husband so he does not inherit assets if the well spouse dies before him. If Wife does not want to disinherit Husband, she can execute a will that includes a special needs trust for the benefit of Husband that terminates upon his death.
Another consideration is determining the appropriate facility for placement. Caregivers are often confused as to which placement option is best. An attorney can discuss the options and can also connect the client to a team of professionals, such as nurses and social workers, who can best help the well spouse navigate through the process.
Part of the Medicaid process is reviewing all of the couple’s income and assets and determining their effect upon Medicaid eligibility. It is important for the client to become educated regarding the applicable regulations so that she can make an educated decision as to whether to proceed with a Medicaid application. Spouses with assets above statutory levels must sign a “spousal refusal” which essentially eliminates consideration of a well spouse’s assets and income when determining eligibility for the Medicaid applicant. In other words, the Medicaid agency will count only the applicant spouse’s income and resources when determining eligibility. However, Medicaid will still review gifts made by either spouse. If either of the spouses has made gifts (transfers) in the past five years, and the recipient cannot return the funds, it may be necessary to pay privately for a period of time before Medicaid begins to cover the cost of care.
Another major consideration is protection of the family home. If there is another individual, such as a disabled child or an adult child who has been living in the home for at least two years, the client should consider the option of transferring the home to one of these individuals because the transfer will fall within the category of “exempt” transfers that have no effect on nursing home Medicaid eligibility. If the couple has a disabled child, the client should also consider creating a special needs trust as part of this plan.
Finally, there are situations in which a couple is estranged and has long been contemplating divorce. It is important to discuss with an attorney any family law issues and how any decisions will affect the Medicaid agency’s review of a Medicaid application.
In addition to these topics, there are many other issues to explore when a spouse is institutionalized and Medicaid is being considered. It is important to meet with an elder law professional who can provide appropriate advice.
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. Stacey Meshnick, Esq. is a senior staff attorney at the firm who has chaired the firm’s Medicaid department for over 15 years.The law firm can be reached at 718-261-1700, 516-466-4422, or toll free at 1-877-ELDER-LAW or 1-877-ESTATES. Mr. Fatoullah is also a partner with Advice Period, a wealth management firm, and he can be reached at 424-256-7273.
Eva Schwechter is an associate with the firm.
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