Transcription:

Cheryl Martin (Host): Many elderly desire to stay independent as long as possible and live in their own homes. LIFE St. Francis helps to make that happen with its comprehensive range of medical and social services. We'll learn more coming up next.

This is St. Francis' Medical Center's Word On Wellness, the podcast brought to you by St. Francis's Medical Center. I'm Cheryl Martin. With me as Lisa Zavorski, the Executive Director of LIFE St. Francis and Anjuli Melo, the community liaison. I'm delighted that both of you are on to discuss this program exclusively for seniors. Lisa, let me begin with you. What is LIFE St. Francis?

Lisa Zavorski: LIFE is a program of all-inclusive care for the elderly, better known as a PACE Program. And just like the acronym of our name suggests, LIFE stands for Living Independently For Elders. And it's an alternative to nursing home placement. And we also are the insurance company, as well as the total care provider for all services that a participant in our program may need. And I'm sure that Anjuli can probably shed a little bit more light on exactly some of the services that we do provide.

Anjuli Melo: So as Lisa was stating, we are Living Independently For the Elderly. So what we provide is comprehensive and coordinated medical care. We also provide social service care for seniors. The goal of our program is to allow our seniors to be able to live safely at home with our services, whether that be provided at our center or in their home. The unique part of this program is there is an interdisciplinary team that consists of clinicians that are really charged with keeping them at home.

Cheryl Martin (Host): How do you know if a person is an ideal candidate for this program, Anjuli?

Anjuli Melo: So we do have some requirements for the program. They have to be 55 and older. They have to be able to live in our service area. So we service all of Mercer County and parts of Burlington County. It's governed by ZIP codes. They do have to meet level of care. We do have a level of care nurse that does an assessment to see if they meet the activities of daily living requirements, and they have to be able to live safely in the community at the time of enrollment.

Cheryl Martin (Host): Now, Lisa, you mentioned, I believe, being a PACE provider. What does PACE stand for?

Lisa Zavorski: A Program of All-Inclusive Care for the Elderly.

Cheryl Martin (Host): And is this a program for the state of New Jersey, or this is a program strictly for St. Francis?

Lisa Zavorski: No, it's across the nation. Right now, there are six PACE Programs in the state of New Jersey. LIFE St. Francis opened our doors in 2009 and we were the first PACE Program in the state of New Jersey. But there are other programs, five other programs in the state, and you can find them in locations throughout the nation.

Cheryl Martin (Host): And this is a question for either one of you. What makes LIFE St. Francis' Program distinct?

Anjuli Melo: So I think that what makes It unique and different is the way you're kind of getting all of your services in one unique location. So we use our center, as not only an adult day, where they're able to come and have socialization and recreation, but then they're also able to see their doctors at the same place.

Normally, these are things that you're doing in different sections, different doctor's offices. And here, it's all in one location. Certain features make it also very unique, such as transportation, and then some of the specialists that you're getting in-house. So, whether that be a podiatrist, a dentist, physical therapy, mental health services as well, everything is in one location.

Cheryl Martin (Host): That's great. So when an assessment is done, does the person giving the assessment then says, for example, "Well, for this senior, these services will take place at home. These will take place at the center." How does that work?

Anjuli Melo: So we do, complete assessments. Based on those assessments, there's different assessors that are going in to do that. We then sit together. And as I mentioned earlier, we do have an interdisciplinary team, and that group of clinicians is creating an individualized care plan for all of our participants.

So once these assessments are completed, we sit down together at a table and we're looking at what are going to be the best services that we can offer? And what would those services look like? Some of them would be in-home depending on what they are. And then, some of them would be at the center because we use both in-home and at the center.

Cheryl Martin (Host): And like you said, it's convenient because you provide transportation, that's inclusive if they need to see a doctor. And again, all those visits are at your center.

Anjuli Melo: Absolutely. We do have a network of specialists that are throughout our Mercer County area. And transportation is included to those doctor's appointments as well. But we do have the availability to be able to pick them up and bring them here to our center to see their doctors.

Cheryl Martin (Host): Now, are family members involved in this application process?

Anjuli Melo: We encourage family members to be involved with the process. Especially if we're dealing with seniors who might have either memory loss or cognitive impairment, we highly encourage for family to be involved, not only for decision-making, but also so that they can be involved with their care.

We also have a large population of seniors who are living with their caregivers, whether that be a daughter, a family member. So when they come to us, we're not only looking at the senior to become a participant, but we're also looking at how we can collaborate and assist the caregiver through this process as well. So we highly encourage participation of family.

Cheryl Martin (Host): What does it take for someone to get enrolled in this program?

Anjuli Melo: So that would look like when we receive the referral or a phone call, we do a phone scrubbing just to get a background of the person. So we're looking at diagnoses, demographic information, we're looking at insurance information. And then, we're looking at the qualifiers for level of care. Once they meet those qualifiers initially, then we set up what we call an in-home assessment and that consists of an intake coordinator, a level of care nurse and an occupational therapist. We will go out and assess the home. We'll speak with them. We'll speak with family members. Once those assessments are completed, we then will come back to meet together with the team to create that care plan. Once the care plan is then created, the intake coordinator then goes back out to the home to review that care plan with either the perspective participant or the family members with the participant. And at that time, they would sign documents in order to join the program.

Cheryl Martin (Host): So I assume there may be some who qualify for no out-of-pocket costs, but then there are some who may have costs, correct?

Anjuli Melo: Correct. So, with the insurance, we receive and we take Medicare and Medicaid. For those who have either Medicaid or Medicare and Medicaid, there is no out-of-pocket expense for them. For those who only have Medicare and if we can help people qualify for Medicaid, we will. But for those who don't qualify for it, there isn't out-of-pocket expense for them.

Cheryl Martin (Host): When a senior qualifies, how quickly can that person become a part of LIFE St. Francis and in the system?

Anjuli Melo: So we enroll for the first of the month, so every month we're enrolling people. we have a deadline to have everything completed, paperwork signed by the 25th of every month for it to begin for the first of that month. So for the month of August, our deadline was August 25th. Whoever was completed by then would start as of September 1st. So it normally takes about a week for us to do assessments, complete care plan, and then have the participants sign in, but it always begins the first of that month.

Cheryl Martin (Host): Can a person use his or her own doctors that they've been going to for a while if they sign up for LIFE St. Francis?

Anjuli Melo: That's a great question. And the answer to that is, unfortunately, no. When they join our program, our doctors become their primary care physicians. It's how we do our coordination of care. So they do have to transition from their current primary care to our doctors here at LIFE St. Francis.

Cheryl Martin (Host): Is there anything else you'd like to add, either one of you, Lisa or Anjuli, about this program?

Lisa Zavorski: I would just like to add the participant benefits. It allows the participant to remain in the home that they love. It avoids nursing home placement. And as Anjuli had mentioned, there are no out-of-pocket medical expenses and we've often had this program described as a very high touch program in the sense that oftentimes we become integrated into a participant's life. And we develop a coordinated personalized care plan for them. And so many members of the team are in, I would say, constant contact with our participants. And you know, it's a very holistic approach to how we manage the care for our participants. But also, all prescriptions, over-the-counter drugs, personal care products, there is no cost for that. Any of the durable medical equipment like walkers canes, grab bars, no cost. We have exercise programs to help improve gait and maintain balance. You know, fall risk is pretty significant in this population. And so we make sure that we focus on prevention. And we focus on really trying to improve quality of life, all aspects of quality of life.

And the other thing I do want to mention is, there's just one phone number that you have to dial. The main number will get you to transportation. We'll schedule all of your appointments. You don't have to wait on the phone for this department or this company to arrange a ride. Or if you don't have a family member available, how am I going to get there? We handle all of that for you. So I think that, for me, it is really the gold standard of being able to coordinate care in this population.

Cheryl Martin (Host): I can definitely see the benefits of that. Anjuli, anything else you wanted to add?

Anjuli Melo: I think that a lot of people misunderstand what is coordination of care. And really, this program encompasses that. Apart from the doctors and insurance and apart from the support that you're receiving, it's kind of like a one-stop shop for medical needs. So once they understand the concept, a lot of people are excited to join a program like this for either reasons, whether they're living by themselves or don't have support, or whether their caregivers are overwhelmed and are having a difficult time piecing things together. We're able to come in and establish the support. And now you have seniors that live comfortably and securely, and you have caregivers who now are able to return to that mother-daughter relationship because it's a different hat when you're a caregiver. So it's nice to be able to see the transitions and see how we can be a value add to our community and to our senior population.

Cheryl Martin (Host): Well said. Thanks to both of you for sharing about this all-inclusive program that grant seniors the desire of their hearts to age in place in their own homes, yet continue to get great medical and social services. Lisa Zavorski and Anjuli Melo, both with LIFE St. Francis. To learn more, please visit lifesaintfrancis.org. That's lifesaintfrancis.org. If you found this podcast helpful, please tell others and share it on your social channels. Be sure to check out the podcast library for other topics of interest to you. And thanks for listening to St. Francis Medical Center's Word On Wellness.