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.”