Our social work team is made up of the most compassionate and caring people we know and they make a huge impact on our patient’s lives. Some may not realize the importance of social workers in the home care field, but they help connect our patients with important resources and programs.
Meet Cassondra and Rachel, two of our Medical Social Workers! They have been gracious enough to provide us a closer look at what their position consists of. For both Cassondra and Rachel, social work is a natural career choice for them because they have always been drawn to helping people. An “average” day can consist of making visits to home health & hospice patients where they complete the appropriate psychosocial assessments, educate about resources, and make necessary referrals for their patient. No two days are ever the same.
Cassondra has always felt that she has been drawn toward the helping profession. While growing up, she thought she would become a teacher. Throughout her life experiences she ultimately determined that teaching was not for her and realized that social work was her calling. Cassondra grew as a social worker while completing hands on internships in a few different fields. She interned with Berks Visiting Nurse Association for 7 months while she was studying for her master’s degree in social work and formally joined our team in June of 2017. Cassondra serves as a medical social worker for both our Berks VNA and Visiting Nurse Association of Pottstown & Vicinity (VNAP). She has the opportunity to serve in home health, hospice and bereavement services as well as assists her colleague, Rachel, with a grant program that helps homebound individuals in Chester County.
Rachel has always had an interest in helping others to help themselves. She is naturally very empathetic and intuitive, two very important qualities to have in this profession. She has extensive experience in in social work and has worked in this field since 2009. Rachel came to our team in February of 2016. Rachel serves as a Medical Social Worker for VNAP.
While there can be many challenges that impact a social workers ability to serve individuals, our team works hard to overcome these challenges so patients can have the best quality of life possible. There are times when our clients have a need but resources to assist them are obsolete or the waiting list can be months or even years. Healthcare and social work are always quickly evolving, which means there is a constant need to learn. While learning new things is great and allows us to provide the best quality of care, it can present some challenges too. Resources and programs have eligibility requirements that change frequently. This can present a challenge when trying to refer patients to a program they need and then figure out they do not qualify. In these instances, it can be tough to find alternative types of care. Home Health is designed to be short term, so our social workers are rarely informed if the referrals made truly benefit the clients’ needs.
Within hospice services, the need for resources is not as prevalent as it is in home health services. With hospice, rapport is built to establish a therapeutic relationship to being providing supportive counseling and necessary end of life education to the patient and their family. While hospice work can be very sad, challenging and heartbreaking, it can also be very rewarding. Cassondra takes on her hospice role as an opportunity to focus on life rather than on death. She feels very fortunate to be able walk beside a patient and their family and witness grace, courage, strength, compassion and patience. She loves having the opportunity to hear and honor her patients’ stories.
Despite the challenges, the positive outcomes always outweigh the negative. Our social workers favorite part of their work is assisting clients in obtaining the appropriate resources to meet their needs as well as watching them succeed and meet their goals. There are many instances where clients are unaware of the types of resources that are available to them. Our social workers take on the role of educating them and beginning the process of utilizing those resources so they can improve the well-being of their clients. It is very rewarding for our social workers to work together with a variety of professionals to better serve their clients and help them improve their quality of life.
Cassondra, Rachel and the rest of our social work team have many different resources that they refer to. Here are just a few that they rely on based on the needs of the patient:
- Obtaining transportation, both public such as Barta, TransNet, PART, Rover, and volunteer such as Diakon, Western Berks Shepherding Ministries, RSVP and Project Hearth.
- Connecting to the local Area Agency on Aging for caregiving services.
- Assisting in applying for government benefits such as Medical Assistance, SNAP, or Cash Assistance.
- Volunteer Services.
- Meals on Wheels.
- Receiving counseling for Medicare Services.
- Educating/Assisting in applying for energy assistance programs such as LIHEAP and Dollar Energy Funds.
- Educating/Assisting in applying for prescription assistance programs such as PACE and PACE NET.
- Education about personal emergency response systems or medical alert pendants.
- Grant programs for home maintenance.
- Caregiver Services
They will also provide education to about certain things such as funeral homes for final arrangements, nursing homes for long term care, power of attorney documents or living wills and subsidized housing, and local churches for spiritual support.
Rachel & Cassondra are just two members of our incredible team of social workers. They, like most in their career field, find their job to be extremely rewarding. People in this career field truly make a positive difference to so many people.
Did you know that we offer easy to use medical technology for patients to utilize in the comfort of their home? Staying up to date with medical technology is critical in every medical field, especially home health. It greatly improves the level of care patients can receive while remaining in the comfort of their own home. It not only helps reduce re-hospitalization rates but it helps patients maintain a higher level of independence which is very important for older adults and family members feel more secure with the level of care their loved ones are receiving.
As many as 1 in 5 chronic disease patients are re-hospitalized within the first 30 days. This has identified a need for patients to be able to receive closer monitoring and follow up so signs and symptoms of worsening can be recognized immediately. Medicare and Medicaid now penalize healthcare systems for re-hospitalizations that occur within 30 days for chronic diseases such as heart failure, Chronic Obstructive Pulmonary Disease (COPD), and diabetes. As a result of these penalties, health systems need to form relationships with home health care agencies who are able to assist them in reducing the re-hospitalization rates and it has prompted the use of medical technology in the home so that patients can be monitored more frequently.
This is where the use of our Telehealth devices come in. The device monitors the patient’s vital signs as well as symptoms associated with what they are being treated for, via electronic transfer of information through phone lines or internet access. We provide Telehealth monitors to our patients who are at a high risk for re-hospitalization. The monitors are user friendly and easy to use and most of the questions that are prompted require the push of a yes or no button or the patient may have to enter numbers if the question asked requires a numerical answer such as weight, blood pressure or blood sugar. If a patient is not comfortable setting it up themselves, we are happy to have a professional from our team do it for them. The Telehealth monitors are used primarily for patients with chronic conditions such as COPD, Diabetes, and Heart Failure as well as for patients who have had an acute MI or who have undergone procedures such as Coronary Artery Bypass Graft, Heart Valve Repair, Transcatheter Aortic Valve Replacement, and total hip or knee replacements.
Our patients receive a daily reminder through the machine to record their weight, blood pressure, vital signs and other symptoms that we need to keep track of. If the patient is not able to get to the machine at the time that it prompts them, they can push any button to start it later in the day. If a patient does not record their signs and symptoms for two consecutive days, we will be alerted and our nurse will follow up with them to check in. If their symptoms or vital signs indicate that they are outside of what would normally be expected for them, there will be an indicator to our nurse that they need follow up with the patient as soon as possible.
There are many benefits of being able to use this type of technology in the home. The Telehealth monitors not only help reduce re-hospitalization rates and allow for individuals to receive patient-centered care from the comfort of their home, but it also helps reduce anxiety and helps to increase independence in older adult. Patients also feel more empowered as they become more educated on managing their chronic disease and they are more likely to embrace and take ownership of their health care plan which leaves them with a higher level of satisfaction.
Today is World Sleep Day! A whole day dedicated to celebrating sleep and dedicating time to shed light on some important sleep issues. It is not news that sleep is vital to your overall health, yet millions of people do not get enough sleep and many suffer from lack of sleep. Giving your body time to rest and recover is just as important is eating, drinking water and breathing. To celebrate this day, we have found a list of fun facts about sleeping. Maybe this will motivate you to go squeeze in an extra nap or go to bed early!
To kick off Patient Safety Week we have compiled some tips on how you can prevent yourself from falling. Falls are one of the leading causes for injury in older adults. Many adults have a fear of falling even if they haven’t fallen before. For some, this means they avoid certain things like walking, shopping, going to social activities, and more. Older individuals have an increased risk of falling for many different reasons including impaired vision, decline in physical fitness, surgical procedures, medications, and more. Falls often lead to broken bones, particularly broken hips, and head trauma. It is important to take preventative measures to decrease the risk of falling.
There are a few basic changes you can make in order to prevent falling and most of them have little or no cost to put in place.
- CONSULT YOUR DOCTOR. Speaking with your Doctor can help identify any health conditions or medications that may contribute to the likelihood of falling. Make sure you are prepared with a list of ALL the medications you take, both prescribe and over the counter. Some medications may have side effects that could potentially increase your risk of falling. Also, make sure you are honest with them as to whether you have fallen before. It is also important to visit your Eye Doctor so that you have the most up to date prescription for your glasses and contacts.
- STAY ACTIVE. This step ties in with consulting your Doctor. When you have the conversation with your Doctor about falling, you should also discuss any recommended physical activity. Staying active will not only help your overall health but it will keep your muscles strong and help with maintaining flexibility, stamina, and coordination. Walking is a great way stay active and you can enjoy this while chatting with friends or window shopping at the mall. Another option is to contact a local gym or senior center and get information about what classes and services they offer.
- DE-CLUTTER. This is probably the easiest way to prevent falls and it does not cost anything. Simply getting rid of stacks of old magazines, newspapers, or anything else in your home that is not needed or used is extremely helpful in decreasing the risk. Especially, if you have things piling up by the door, in a hallway, or on the stairs.
- REMOVE OR REPAIR ANY TRIPPING HAZARDS. Is there an area rug that does not stay put, or an extra end table crammed into a room that partially blocks the entrance? Get rid of it. Is there an extension cord that goes across the room? Move it. Is there a piece of carpet that keeps coming up, or a floor board that is loose? Fix it. Anything that is in the way or needs to be repaired should either be removed or fixed so that falls can be prevented.
- INSTALL HANDRAILS AND GRAB BARS. Having the extra support when going up and down stairs, by the toilet and shower, or anywhere else that it may be needed is crucial in preventing falls. If this is not something you can install yourself, it is best to enlist the help of a family member or handyman.
- INCREASE LIGHTING. Make sure your house is properly lit. Installing brighter lights in hallways and stairwells as well as in the bathroom is a cheap and effective way to minimize a potential fall risk. It may also be beneficial to invest in some nightlights for your hallway and bathroom so that it is easier to navigate around your house at night, especially if you wake up frequently to go to the bathroom or get a drink.
- TAKE YOUR TIME. Be careful when moving around. Take it slow if you are not comfortable with your mobility level. Simply pausing when transition from laying down to sitting up, sitting up to standing up, and before going up and down stairs can help greatly. Moving too fast can put you off balance and if your reflexes aren’t as good as they used to be, you may not be able to catch yourself.
- INVEST IN NON SLIP MATS. Putting non slip mats in an area that is prone to getting wet is an easy way to help avoid the possibility of slipping. That means putting them inside and outside of the shower, in the kitchen and laundry room, as well as at any entrances to the house.
- WEAR SHOES OR STURDY SLIPPERS. Sure, socks and fluffy slippers are more comfortable, but they are not helpful. They do not provide proper support and they increase the risk of slipping or falling. It is important to wear proper fitting shoes or slippers with hard, sturdy bottoms. If shoes are too uncomfortable, you can also opt to wear socks that have the grips on the bottom of them.
- WEAR PROPERLY FITTING CLOTHING. If you are wearing loose or baggy pants, it is increasing your risk of tripping or slipping and falling down. Opt for better fitting or hemmed clothing that does not drag on the ground.