Jewish Senior Living magazine   2016/2017


An innovative program developed by the Jewish Home is ensuring that “at risk” patients who return to their own residences after rehabilitation at the Home are safe and comfortable.

Many of the patients leaving STARS, the Jewish Home’s short-term and rehabilitation services unit, return to homes where adequate care is not immediately available, observes Edwin Cabigao, the Home’s chief nursing officer. “I notice that lots of STARS patients live alone, or are being taken care of by aging spouses or disabled children,” he says. These are considered high-risk patients.

So Edwin created Peace of Mind. The program ensures the transition from STARS (where the patient’s needs are met by a full range of professionals and trained staffers) to home (where they may be on their own) is made as easy as possible.

“The primary goal is to maintain patient safety,” he says.

Peace of Mind offers a safe and individualized discharge and home-care plan by partnering with community homecare agencies for three hours of services provided by caregivers who help high-risk patients move back to their own homes. It includes escorted transportation to the patient’s home; picking up needed medications at a pharmacy and setting up a medication system; moving furniture, if needed, to accommodate a walker or wheelchair; grocery shopping and meal preparation; light housekeeping; personal grooming; and confirming or setting up doctors’ appointments.

Edwin believes the Home is the only facility providing this important service. “The Jewish Home pays for the caregiver to be with the patient for these hours. It’s a budget item that’s well worth the cost.”

“It’s a huge transition to go from skilled nursing back home,” explains Gideon Mohler, a case manager whose duties involve overseeing medical and skilled care and dealing with insurance. It takes 24 to 48 hours after a patient is discharged for home healthcare services, if applicable, to begin. “Peace of Mind helps fill the gap during this tricky period.”

Patients are often anxious when they leave STARS, notes case manager Susan Ramos. “They’re going home with a condition they didn’t have before. Knowing that someone will be there eases their mind.”

Part of Susan’s job is to sit down with each patient and find out what he or she is worried about. Often their concerns are issues around housekeeping, mobility, and personal needs: Now that I use a walker, will my furniture be a hazard? Has the food in my refrigerator spoiled in the two weeks I’ve been away? How will I make dinner? How can I start taking my medication when I can’t drive to the drugstore? Caregivers, who greet patients when they arrive home, handle all these concerns, and more.

Peace of Mind was designed to assist patients, but they are not the only ones who benefit, Gideon affirms. “It also gives us peace of mind to know our patients are safe and well taken care of when they leave us.”

Going from skilled nursing to back home is a huge transition, says Jewish Home case manager Gideon Mohler. Peace of Mind program helps fill the gap.

Mario Lemay, director of utilization management, and case manager Susan Ramos discuss a patient’s discharge plan.


In STARS, where patients are admitted for short-term rehabilitation after a hospital stay, case managers are key to coordinating the patients’ comings and goings, as well as the variety of treatments that help them recover and return to their normal lives.

“Our case managers also deal with the emotions of family members. They explain and they pacify,” says chief nursing officer Edwin Cabigao. “In addition, they work with insurance companies that approve the number of days a patient may stay in STARS. Essentially, case managers are dealing with people and dealing with complexities, but they’re doing it in a compassionate way; they’re not just looking at numbers. It’s care with a heart.”

“Case managers are strong clinical advocates for our patients,” says Mario Lemay, director of utilization management, who administrates the case management program. “For example, they analyze the needs of the patient and then work in collaboration with the insurance company so that the treatments can be covered.

“The flow should always be towards home,” he emphasizes. Within the first week of admission, a family conference is organized with the care team to determine equipment and resources that will be needed when the patient returns home. The Jewish Home partners with some 15 home healthcare agencies that will take over the care once the patient is discharged. “We ensure there’s a safe transition between here and home, and then keep in touch, both verbally and electronically,” he expands.

“Our aim,” says Edwin, “is to be sure everyone is safe, happy, and satisfied in the highest manner.”

Edwin Cabigao

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