For eight years I had the honor of working alongside some of the most dedicated nurses I have ever had the pleasure of working with in my 25 year nursing career. Dedication to their clients and their level of professionalism encouraged and supported all of us to provide the best care we could to our clients. These are the nurses of Jewish Family Service of Central New Jersey (JFS) who make home visits to a population of chronically ill clients who require assistance with activities of daily living, health monitoring, and health education in order for them to remain where they are most comfortable: their own homes.

Our nurses also provide supervision to a staff of 45 Home Health Aides who provide homecare services to homebound elderly. In honor of National Nurses Week, May 6-12, celebrating ethical practice and quality care, I would like to take this opportunity to highlight the nurses at JFS and the work that they carry out daily to enable their clients to age in place safely athome.

As the chronically ill senior population continues to rise, agencies are trying to come up with ways to meet the demand and to offer the best services to these clients. JFS has created an innovative way of delivering these services. The nurses work alongside social workers in order to offer a holistic approach when it comes to care in the home.

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Often these clients present with a multifaceted situation that requires a multifaceted approach to ensure their wellbeing. JFS’s Transitional Care program, comprised of a nurse and social worker, has found that there are usually several reasons that clients become ill after hospital discharge, requiring frequent re-hospitalizations, including socio economic reasons as well as physiological. The social workers address the socioeconomic issues while the nurses concentrate on the physiological. This team approach is what sets JFS professionals apart.

Initially started with a generous grant from The Grotta Fund for Senior Care, the JFS Transitional Care Program is now part of a Federally funded Community Care Transition program to prevent re-hospitalizations and reduce Medicare Costs, and funding from The Elizabethtown Healthcare Foundation in Elizabeth. The nurse-social work team approach has also been utilized for the Alzheimer’s/Dementia Caregiver Support Program funded by the Healthcare Foundation of New Jersey, the Jewish Community Foundation of the Jewish Federation of Greater MetroWest NJ and the Merck Foundation.

The program is a partnership between the Jewish Family Service of Central NJ and the Jewish Family Service of MetroWest NJ to provide support to both the Alzheimer’s/Dementia patients and their caregivers. At JFS Central NJ, the nurses and social workers have the ability to refer clients internally to each discipline as needed. Often, home visits are made together in order to evaluate the various aspects of a client’s situation and offer the most comprehensive approach to their care.

One of the ways that the nurse/social worker team approach works is holding family meetings. After a client’s needs are assessed a plan of care is formulated and tailored to the specific needs of the client. Families are involved in the plan especially when the client is found to have safety needs that require modifications to the home such as bathroom safety equipment, or it is recommended that the client have additional assistance at home. Assistance in implementing these care plans has been made possible due to the generosity of foundations such as the Fred C. Rummel Foundation and the Wallerstein Foundation for Geriatric Life Improvement.

Having all of the participants in a client’s care in one room, having the same discussion, has been shown to be very effective in communicating the needs of the client and formulating the aspects of the plan that specifically addresses areas of concern. This enables the client to continue to remain at home, with supportive services as well as professional monitoring. The plan is reevaluated often, and modifications are made based on the changing needs of the client. The nurse and social worker continue to work together to address issues and concerns as they arise and are available to the client and family as resources and to ensure that the plan reflects the changing needs of the client.

Among other roles the nurses play at JFS, advocacy is a major theme throughout the nurses’ approach to clients. As a basic tenet of quality nursing care, advocacy is fully supported and expected as a JFS professional nurse. While always taking the clients goals for health and well being into consideration, the nurses formulate plans of care that reflect the specific needs of each client. Advocating for the clients incorporates both health related issues such as access to foods that will complement their specific dietary needs, to acting as a resource for both client and family in assisting with end of life preparations or transition to a different level of care.

Clients’ safety and rights are the driving forces behind the nurses’ tireless advocacy. As a JFS standard of care, as well as the theme of this year’s National Nurses Week, quality of care and ethical practice is the backbone of the care delivered by the nurses at JFS. The team approach is a shining example of this level of commitment to their clients. Within an agency that fully supports the highest level of care, the nurses are given the opportunity to utilize their skills and expertise while collaborating with the social workers to offer the most comprehensive plan to chronically ill clients that will address their changing needs as they age at home.

Karen Winter, RN, BSN, served as Director of JFS Nursing Services from 2010-2013 and was on staff as a nurse since 2006. She is now the training coordinator for the Union County Home Health Aide Training Program held twice a year at Jewish Family Service of Central New Jersey and is a JFS Nurse Consultant.