With a goal to provide comprehensive home care, CenterLight Healthcare System offers the Program of All-Inclusive Care for the Elderly, which serves more than 3,000 patients in the five boroughs, Westchester and Long Island. PACE participants must be Medicaid and Medicare eligible and in need of nursing home level care, but able to live at home safely.
“PACE is an interdisciplinary team-driven program with the nurses at the center coordinating care, and we have more than 100 RNs who work in the program,” said Mary Wehrberger, vice president, clinical operations at CenterLight.
At each of the sites, a day health and treatment center serves as a central place for patients to socialize and receive healthcare services from nurses, physicians, social workers, physical and occupational therapists, and nutritionists. Patients also are provided with transportation to and from the center and to medical appointments.
Coordination of careElena Robledo, RN
“Our patient education, whether in the home or at the center, is critical to keeping patients safely at home. We may see a patient who takes 30 medications, four of which are duplicates; a patient who calls 911 when he feels dizzy; or a patient who is alone and has no social outlets,” said Elena Robledo, RN, BSN, membership development nurse at the Chrystie Street, Manhattan site. Robledo was born and raised in the same neighborhood in which she works.
After receiving a patient referral, Robledo meets with the patient and completes an in-depth medical evaluation. “We develop a care plan based on the patients medical needs, functional status and psychosocial concerns,” Robledo said. “Coordination of care is key to our nursing role, and we work directly with our multidisciplinary team.”
At the Stillwell site in Brooklyn, N.Y., Rosemonde Semexant, RN, BSN, is a day treatment and day center nurse. When the centers physical therapist cannot treat a patient because of an elevated blood pressure reading, Semexant sees the patient and notifies the onsite physician, and in a matter of minutes, the clinical manager and field nurse who follow the patient at home are notified about the patients condition, Semexant said.Paul Nadal, RN
Just by nature of their diverse locations in New York City, PACE staff speak more than 75 languages and are trained to serve the unique healthcare needs of patients in their communities.
At the East Harlem location, Eileen OBrien, RN, BSN, comprehensive care manager at CenterLight, oversees and coordinates care for about 270 patients who come to the day health and treatment center and may receive meals, comprehensive healthcare services, social time, recreation and support for daily living activities. “Its a busy and fast-moving place where on any one day you might see patients receiving their daily insulin or wound care services; some participating in a drumming circle to alleviate pain; and others being helped with showers and personal care,” said OBrien, who has worked at the site for 16 years.Rosemonde Semexant, RN
The East Harlem location serves a primarily Hispanic community, and OBrien and staff often focus their care and education on healthcare issues related to diabetes and obesity.
“I view myself as a triage nurse at home, and I can intercept hospital visits through my proactive care,” said Wanda Rodriguez, RN, BSN, community health nurse at the Wallerstein site in the Bronx.
It might require a call to the CenterLight physician, an order placed to the pharmacy and a review of the side effects of the medication with the patient, all in one visit. If patients need to go to the hospital, they can be cared for by CenterLight physicians if they are admitted to Montefiore, which makes for better continuity of care, Rodriquez said.Wanda Rodriguez, RN
“Its rewarding to help a new diabetic learn how to administer insulin, record their fingerstick results and adjust to a new diet,” said Paul Nadal, RN, COC, community health nurse at the East Harlem location. Nadal is responsible for about 30 patients. “I am independent and collaborative in my role, and it is a privilege to help patients in their own homes.”
For more about the PACE program, visit www.CenterLightHealthcare.org.