At North Shore Elder Services (NSES), we have a team of ten Registered Nurses (RN) with over 263 years of collective experience. These nurses are called Clinical Assessment and Eligibility Nurses (CAE). They are part of what is referred to as interdisciplinary care management at NSES.
Interdisciplinary care management is provided by Registered Nurses and Care Managers (CM) working in consultation with physicians, nurses, and therapists from home health agencies, Hospice providers, nutritionists, housing managers, mental health professionals and other home and health care professionals.
Amanda Cannella, RN, is the Manager of our nursing team and the expert on the services a NSES’ nurse provides. Amanda describes her staff as very dedicated and “a very caring group of nurses.” “Incredibly, between all ten of us we bring 263 years of experience to our consumers!”
What is the role of the CAE nurse?
“The nurse assesses for clinical eligibility for various programs that are offered through NSES, whether MassHealth (Medicaid) or Home Care. We follow regulations established by the Executive Office of Elder Affairs and the Executive Office of Health and Human Services to determine eligibility for each program. Eligibility is determined by the nurse completing a comprehensive in-home needs assessment to identify issues or problems that may be affecting a consumer’s secure independent living at home. It is also important in our role to help the consumer, if able, to advocate for themselves in the planning of services.”
What can be expected when a nurse comes to a consumer’s home?
“We perform a head to toe assessment. We check vital signs and listen to lungs. We ask many questions such as; when did you last see your primary care provider? How do you get to your appointments? Who does the grocery shopping? Who prepares meals? Are you able to bathe and/or shower yourself? Do you have a hand-held shower and shower seat? Do you need a podiatrist? Have you experienced any falls?”
“We review all the medications someone is taking and make sure they understand what they are taking. During that first visit we ask about their medical history. On subsequent visits, we discuss what has occurred or changed since the last visit. That is an advantage of our nurses each covering a specific territory; they are able to develop an ongoing relationship with the consumer.”
“The nurse assesses how someone ambulates and determines what their functional level is. We evaluate whether or not someone is at high risk for falls. We would look to see if there are any stairs in the house and how the person navigates those.”
“The nurse assesses if someone needs physical therapy or occupational therapy; if someone needs durable medical equipment such as grab bars, raised toilet seats, etc.; and if someone is eating nutritious meals.”
“This first visit lasts about an hour for the nurse to gather all the assessment information needed to work with the consumer to develop an individualized care plan.”
“It is the nurses’ responsibility to work with the consumer to determine the level of care and what type of worker will provide that care. There are personal care workers, home health aide workers, and supportive home care aides.”
Does the nurse provide any hands-on care?
“During this visit, the nurse is assessing the ability of the consumer to provide for their care. They are not providing direct care that would have been ordered by a physician such as wound care or medication management. The nurses provide education around disease process, medications, health planning and caregiver support. If the consumer is experiencing a medical event, the nurse will help the consumer access the help which may include contacting the primary care physician.”
What happens after the nurse completes the in-home assessment?
“Every situation is a little different. After the home visit, the nurse will discuss the visit with the consumer’s care manager. The nurse determines which program might be most suitable, discusses the consumer’s goals, preferences, and needs with the care manager and then the care manager contacts the vendor agencies we contract with to set up the services. Services will typically start within one week, however, depending on the hours requested and the type of service needed, it may be slightly longer.”
Who makes referrals for nursing services?
“Anyone can call with inquiries about nursing services. As the nurses are determining eligibility for various programs, most referrals are internal. However, calls may come from nursing facilities, physician offices, or the general public to inquire about needed services.”
How many consumers does a nurse see in a month?
“The nurse sees approximately 24-36 consumers each month.”
How often does a nurse visit a consumer?
“On average, nurses visit each consumer every six months. However, more visits occur if there have been changes for the consumer that need to be reassessed. The visits are staggered in between the care manager’s visits so every three months the consumer is being seen by either a care manager or a nurse. The nurses and care managers keep each other up to date with the consumer’s health needs and or changes needed after their respective visits. .”
Do the nurses discuss long-term care placement with family members and/or consumers?
“Many times family members will ask the nurse about long term care options. Our goal is to educate consumers and family members about all community options first. If long term care placement has been decided upon, the nurse will encourage the consumer/family to tour the facilities and meet with staff at the facilities. The care manager can be consulted with questions/concerns by the consumer also.”
“Two of our nurses are designated as CSSM RNs (Community Screening Service Model) and visit each of the Skilled Nursing Facilities in our catchment area weekly. They meet with consumers who have MassHealth as their primary or secondary insurance and determine whether the consumer meets the eligibility criteria for MassHealth to pay for their facility stay. The nurse also works with residents in the facility whose goal is to return back to the community. The nurse will attend discharge planning meetings and work with the care manager to arrange identified services.”
North Shore Elder Services offers many different programs and services through private donations and state and federal contracts. If you are interested in learning more about the services at NSES, you can call us at 978-750-4540 or check our website at www.nselder.org. If you would like to make a referral for yourself or someone you are caring for, you may also visit our referral page at https://nselder.org/contact-us/referral-form/