Nurses are key to an aging-in-place plan
For eight years I had the honor of working alongside some of the most dedicated nurses I have ever had the pleasure to work with in my 25-year nursing career. Their professionalism and their devotion to their clients encouraged and supported all of us in our efforts to provide the best care to our clients. These are the nurses of Jewish Family Service of Central NJ, who make home visits to a population of chronically ill clients requiring assistance with activities of daily living, health monitoring, and health education in order for them to remain where they are most comfortable: in their own homes.
These nurses also supervise a staff of 45 health aides who provide homecare services to homebound elderly.
In honor of National Nurses Week, May 6-12, celebrating ethical practice and quality care, I would like to highlight the JFS nurses and the work they carry out daily to enable their clients to age in place safely at home.
As the population of chronically ill seniors grows, agencies are seeking ways to meet the demand and offer the best services. At JFS, nurses work alongside social workers to offer a holistic approach to care in the home. Clients with multifaceted challenges require a multifaceted approach. There are usually several reasons — socioeconomic as well as physiological — that clients become ill after hospital discharge, requiring frequent re-hospitalizations. Under JFS’s Transitional Care Program, social workers address the socioeconomic issues while the nurses concentrate on the physiological.
Started with a generous grant from the Grotta Fund for Senior Care, the JFS Transitional Care Program is now part of a federally funded Community Care Transition program to prevent re-hospitalizations and reduce Medicare costs, and receives funding from the Elizabethtown Healthcare Foundation in Elizabeth.
The nurse-social worker team approach has also been used for the Alzheimer’s/Dementia Caregiver Support Program funded by the Healthcare Foundation of New Jersey, the Jewish Community Foundation of Jewish Federation of Greater MetroWest NJ, and the Merck Foundation. The program is a partnership between JFS of Central NJ and Jewish Family Service of MetroWest NJ, both federation agencies.
At JFS Central, the nurses and social workers have the ability to refer clients internally to each discipline as needed. Often, they make home visits together in order to evaluate a client’s situation and offer the most comprehensive approach to their care. After a client’s needs are assessed, a plan of care is formulated and tailored to the needs of the client. Families are involved in the plan, especially when the client is found to have safety needs requiring home modifications, such as bathroom safety equipment, or additional assistance at home. Implementing these care plans has been made possible thanks to the generosity of foundations, including the Fred C. Rummel Foundation and the Wallerstein Foundation for Geriatric Life Improvement. Having all the participants in a client’s care in one room is vital; it enables the client to continue to remain at home, with supportive services as well as professional monitoring. The plan is reevaluated often, and modifications are made based on the client’s changing needs. The nurse and social worker continue to work together to address issues as they arise and are available to the client and family to ensure that the plan reflects the client’s changing needs.
Advocacy is another major theme among the nurses at JFS when formulating plans of care. Advocating for clients incorporates both health-related issues, such as access to foods that will complement their dietary needs, to acting as a resource for both client and family in assisting with end-of-life preparations or transition to a different level of care. Clients’ safety and rights are the driving forces behind this tireless advocacy.
Quality of care and ethical practice is the backbone of the care delivered by the nurses at JFS. The team approach is a shining example of their commitment to their clients, with the nurses employing their skills and expertise within an agency that fully supports the highest level of care. Collaborating with the social workers allows them to offer the most comprehensive plan to chronically ill clients as they age at home.