Compassionate care for the elderly

The Maimonides Home Medical Care for the Elderly Program is a home-based primary care service that delivers holistic, personalized, coordinated, high-quality medical services to homebound elderly individuals in the comfort of their homes. Our nurse practitioners visit patients at home at regular intervals, or as needed, to provide a variety of health services. The treatment plans focus on maximizing independence and function at home. We serve multiple areas including, Manhattan Beach, Brighton Beach, Bensonhurst, Bay Ridge, Sheepshead Bay, Mill Basin, Borough Park, Sunset Park, Midwood, Park Slope, Marine Park, Gravesend, Bath Beach, Dyker Heights, Fort Hamilton Kensington, and Windsor Terrace.

Knowledgeable, personalized care at home

  • 24-hour answering service
  • Active involvement with patients, their families, and home care nurses
  • Arrange diagnostic and laboratory tests at home
  • Assessment of the home environment
  • Assistance with psychosocial and healthcare needs, including prescriptions, home care, supplies, and forms
  • Coordination of care and referrals to nursing, social work services, and medical specialists as needed
  • End of life counseling and hospice referrals
  • Guidance and information regarding advance directives and appointment of a healthcare proxy
  • Health education, nutritional counseling, and vaccinations
  • Multilingual staff

Safe at Home

Safe at Home is a demonstration project designed to transition high-risk older patients from Maimonides to home effectively by providing enhanced discharge and transitional medical house calls from the Safe at Home team’s nurse, social worker, and Nurse Practitioners (NPs).

What happens if I need to be hospitalized?

Our patients are admitted to Maimonides Medical Center under the care of a physician from the Division of Geriatrics. Most admissions will be to the Acute Care for Elders (ACE) Unit. We will facilitate and coordinate all hospital admissions and discharge plans.

What is the project design?

Hospitalized elder patients and their caregivers will meet the Safe at Home team prior to hospital discharge. The team, in conjunction with case management, will instruct the patients and their families on safe discharge. Then, they will review the plans for home, including medications, and follow-up care. The team will ensure the coordination, education, and continuity of healthcare, as patients transition from the hospital setting to their homes. The patients and their families will meet an NP, who will come to their homes for a period of 30 days and/or up-to 3 months.

What are the project’s goals?

  1. To determine whether an enhanced hospital discharge and NP home visits prevent readmissions to the hospital, reduce emergency room visits, and prevent nursing home placements
  2. To improve patient, family, and physician satisfaction with hospital discharge policy
  3. To prepare for legislative mandates for coordination of care across settings and among providers (such as Medical Home and Accountable Care Organizations)

Who is eligible?

  • Aged 65 and older
  • Homebound (limited ability to leave home because of illness or injury. The individual needs the aid of supportive devices, the use of special transportation, or the assistance of another person to leave their place of residence)
  • Patients with chronic medical conditions such as:
    • Arthritis
    • Chronic pain
    • Confusion
    • Decreased mobility with the risk of falls
    • Dementia
    • Depression
    • Diabetes
    • Difficulty breathing
    • Functional decline
    • Heart Disease
    • Loss of hearing/vision
    • Osteoporosis
    • Parkinson’s disease
    • Stroke
    • Terminal illness
    • Weight loss/malnutrition
    • Wounds and pressure ulcers

What is your role as a caregiver?

During your patient’s hospitalization, your encouragement to take advantage of this enhanced discharge and transitional home care opportunity is very important. After discharge, you will be working collaboratively with a home-visiting NP on the patient’s management for up to 3 months, a determination that will be made in consultation with you. Finally, the NPs will communicate with you predominately by Maimonides’ secure email.

What are the benefits of participating?

We expect improved satisfaction for your patients and their families, not only with their transition from hospital to home but also with their enhanced capacity to live at home with greater safety and confidence. In addition, you will be in the vanguard of physicians who are involved in the design of best practices for coordinated transitional care. You will be using electronic information and communication technology, all of which will be part of new healthcare mandates, and financial incentives for physician involvement in transitional care programs.

Our Home Medical Care Team

If you would like to learn more about the Safe at Home Program, please contact the Division of Geriatric Medicine:

Debra Barnett, GNP, Program Director: (718) 283-6233
Aleksandra Zagorin, DNP, MA, AGPCNP-BC, RN: (718) 283-6051

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