By Carol Gordon DeLooper, APN, FNP-BC
What nurse practitioner Ahone Ngalame enjoys most about working with a New Jersey-based senior program is being able to collaborate with a team that helps approximately 300 seniors receive the healthcare they need while remaining in their homes.
“I’m able to work as part of a team in my role as a primary care provider, and when I need consultant and collaborative resources, they are available,” Ngalame said.
She works with Living Independently for Elders, LIFE, the local name for Program of All Inclusive Care for the Elderly or PACE, developed in the early 1970s to help frail seniors stay in their homes. Medicare and Medicaid provide funds for the program.
Opening in 2009, LIFE St. Francis is one of four PACE programs in New Jersey; 31 other states also participate. St. Francis Medical Center in Trenton, N.J., administers LIFE St. Francis, with sponsorship by Hope Ministries. Most LIFE senior participants live at home in Mercer or Burlington County. Their healthcare needs are coordinated from the LIFE center, which includes adult day care services, recreational activities, physical and occupational therapy services, social services and wellness visits as well as transportation from their homes if needed.
Most of the participants’ healthcare needs can be met living at home and by using the center as the centralized hub for their healthcare. However, if a participant’s healthcare is too complex or it is unsafe to provide the services at home, they may live in and receive their care at assisted living facilities or nursing homes.
The program continues to follow participants through their life span, including when they require end-of-life care.
Ngalame provides primary care at the LIFE wellness center, visiting with the participants and analyzing and interpreting lab and radiology results. She also attends family meetings and consults with the provider network for care coordination. At family meetings, Ngalame may discuss goals of care, offer education on a family member’s needs and seek ways to improve care. These meetings build trust, enabling LIFE staff to become a friendly, welcome presence in the participants’ lives, according to Ngalame.
She meets daily with an interdisciplinary team that includes nurses from the wellness center as well those in home care, home health aide supervisors, the center’s site director, physical and occupational therapists, social workers, registered dietitians and transportation and recreation therapists to advocate for the patients and make care decisions. The team discusses subtle changes in a participant’s physical, cognitive and functional statuses.
If left unattended, these changes could lead to hospitalization. For example, if an insulin-dependent diabetic cancels a scheduled attendance day because of diarrhea, a nurse will call the participant to see if a home care nurse visit is necessary. The nurse may also arrange transportation to bring the participant to the wellness center, for assessment, intravenous hydration and lab work.
“We are a team working together to make decisions and life plans for our participants,” Tracey Martin, RN, LIFE medication room nurse said. “No issue is too big or too small. Everyone from every discipline collaborates to solve each and every issue that arises with our participants. That is so different to me than working in a hospital or rehab center where you never really know your patient or their family, or their real life.”
Carol Gordon DeLooper, APN, FNP-BC, is a family nurse practitioner for Lawrenceville Internal Medicine in Lawrenceville, N.J. and a former employee of LIFE St. Francis.