Older Adults
UPMC Staying-At-Home Program
About Us
Why Use Staying-At-Home
Meet Our Staff
What is Client-Centered Care Coordination?
Benefits of Client-Centered Care Coordination
Members of the Health Care Team
Levels of Service
How Do I Get Started?
Contact Us
About Us
UPMC Staying-At-Home is a client-centered care coordination program offered to older adults (clients) living in their own home, in an assisted living facility or in a retirement community in Allegheny County. We utilize a proactive preventive approach to geriatric care, which provides optimal care for all clients, regardless of health or debility by “raising the floor of care.” Optimal care is defined as the high-quality care the client needs—consonant with his/her values and goals—when needed, from the most appropriate person, and in the most appropriate setting.
Optimal care is also proactive and preventive and less costly in the long run. The primary goal is to keep the client independent and safe in his or her own home for as long as possible.
What is “Raising the Floor of Care”?
- Actively engaging the client and family member in his or her health care
- Assigning a social service professional to effectively coordinate care and serve as a interface between health care team members and the client
- Assuring that the client receives timely preventive care, immunizations and preventive health screenings
- Developing a care plan based on results from the client’s periodic functional and cognitive assessments and medication reviews
- Assuring a smooth transition from pre-hospital to post-hospital care for the client and family member
- Assisting the client in setting up and maintaining a personal health diary that contains all his or her pertinent health care information
Why Use Staying-At-Home?
Staying-At-Home is an integrated client-centered care coordination program featuring:
- The ability to transfer the responsibility of care coordination to us to give you peace of mind and allowing you to spend quality time with your family member.
- Services provided 24 hours a day, 365 days per year by our employees, who are all professionals specially trained in the care of older adults.
- Care coordinators who coordinate care across the continuum from acute care to long-term care to home.
- Employees who are bonded. We pay their employee taxes and worker’s compensation too!
- Clinical capabilities in geriatric care that are the best in the region. As a program of the University of Pittsburgh Medical Center, we are part of the most comprehensive network of geriatric services in western PA, including the largest number of trained geriatricians in the region.
- A choice of two levels of services to allow you to spend quality time with your family.
Meet Our Staff
Eric Rodriguez, MD – Medical Director
Janetta Sobinsky, RN – Program Manager
Missy Sovak, MSW – Manager, Care Coordination
Charlotte Birchard, RN – Nursing Services Manager
Jamie Donnell, BSW, PCHA – Manager, Marketing and Intake
Eric Rodriguez, MD – Medical Director
Dr. Rodriguez is an Associate Professor of Medicine in the University of Pittsburgh School of Medicine Division of Geriatric Medicine. Dr. Rodriguez held many administrative positions including the Interim Chief of the newly established Division of Geriatric Medicine, immediate past Medical Director of the UPMC Senior Care-Benedum Geriatric Center, UPMC Montefiore and past Medical Director of two senior living communities affiliated with UPMC, He has received many honors in teaching and clinical services, each year since 1986 and has been listed in the Best Doctors in America: Northeast region since 1996, The Best Doctors in America since 1998 and Guide to Top Doctors since 2002. He provides primary care and consultative services to older adults at the UPMC Senior Care-Benedum Geriatric Center at UPMC Montefiore Hospital.
Janetta Sobinsky, RN – Program Manager
Janetta Sobinsky has been a part of the UPMC system since February 1998, working for Homecare IV Team and as a Clinical Supervisor for Utilization Review and mental health case manager. For the last six years she has been the Nursing Coordinator and Clinical Supervisor of UPMC’s private duty nursing. In addition to her UPMC experience, Janetta also has seven years experience in Oncology, three years in Skilled Care Case Management and as Administrator on Duty in acute care.
Missy Sovak, MSW – Manager of Care Coordination
Missy Sovak received her Masters Degree from the University of Pittsburgh and is a licensed clinical social worker in the state of Pennsylvania. She holds a certificate in gerontology from the University of Pittsburgh. Ms. Sovak is also a Board Certified Diplomate in Clinical social work and a member of the Academy of Certified Social Workers and the National Association of Social Workers. She has been a clinical social worker for the UPMC Living-at-Home Program for 15 years and has been the manager of the program for three years. The Living-at-Home Program is a UPMC subsidized case management program, in a defined geography, for clients 70 years and older who meet the federal poverty guidelines, with a mission of keeping them in their own homes for as long as possible.
Charlotte Birchard, RN – Nursing Services Manager
Charlotte Birchard has been an employee of UPMC system since May 1988. She has worked as an acute care nurse at UPMC in Transplant and Orthopedics . For the last several years Charlotte has been the Clinical Supervisor in Home Care, Nurse Coordinator and Nurse Manager in UPMC Private Duty.
Jamie Donnell, BSW, PCHA – Manager, Marketing and Intake
Jamie Donnell is Marketing and Intake Manager for the Staying-At-Home Program, and Liaison for the Senior Information and Referral Center with the University of Pittsburgh Institute on Aging (UPIA). She holds a Certification in Gerontology, and has spent the last 13 years working in the field of gerontology in a variety of settings. The past seven years, Ms. Donnell has held positions in social work and case management at UPMC. She received her BSW from Indiana University and is a Licensed Personal Care Home Administrator in the state of Pennsylvania.
What is Client-Centered Care Coordination?
Keeping our focus on the wishes and desires of our clients as well as on their needs is the heart of “client-centered care coordination.”
Client-Centered Care Coordination keeps the client’s needs in mind by:
- Developing a care plan based on the client’s strengths, interests, abilities and capabilities
- Engaging the client in deciding upon the direction of care based on his or her capacity to learn, grow and change
- Focusing on “What matters to the client” and not “what’s the matter with the client”
- Providing support and peace of mind to family members by helping the client to safely live independently for as long as possible
What are the potential benefits of Client-Centered Care Coordination?
Client-Centered Care Coordination ensures:
- A consistent single plan of care, even when multiple geriatric health care team members are involved
- A care plan that meets the client’s physical and psychosocial needs by taking into account the status of the client’s emotional well-being, functionality, household maintenance abilities, and social support networks
- Improved communication between health care team members, the client, and family members, which may lead to additional benefits, such as:
- More enjoyable family visits
- Increased adherence with physician office visit recommendations
- Fewer unnecessary hospitalizations and emergency room visits
- Delayed placement in an assisted living or a nursing facility
- Smoother transitions back to home from a hospital or a nursing facility
Members of the Geriatric Health Care Team
Optimal geriatric care is provided by a team, both at home and outside the home. The care is coordinated by a care coordinator who helps coordinate the services provided by the various team members. The Staying-At-Home (SAH) Client’s Care Team Members may include:
SAH Care Coordinator
SAH Concierge
SAH Medical Director
Geriatrician
Geriatric Nurse Practitioner (GNP)
Home Care Nurse
Home Health Agency
Hospital Health Care Team
Nursing Home Team
Personal Care Assistant
Pharmacist
Primary Care Physician
Social Worker
Specialty Physicians
Therapists
SAH Care Coordinator - is a social service professional trained in gerontology who coordinates care among all the team members including the client. The care coordinator will make home and telephonic contacts with the client to assess the situation, discuss solutions, develop a plan of care and help the client follow the plan of care.
SAH Concierge – is a community resource specialist knowledgeable in health and support services for older adults and who coordinates intake and referral for services needed by the client. A concierge is assigned to each client enrolled in the Concierge Level of care in the SAH program.
SAH Medical Director – is a geriatrician, who is a physician specially trained in care of the elderly. The SAH Medical Director guides and directs the clinical program of the SAH. The SAH Care Coordinator and other Staying-At-Home health care team members reviews each client’s care plan with the SAH Medical Director on a periodic basis to assure that the care plan is developed following the geriatric principles of care. The Medical Director may also be available to make house calls or speak to the client, family member, primary care physician or other specialists as needed.
Geriatrician – A physician who has received additional training in providing care to older adults. If the geriatrician is not the client’s primary care physician (PCP), the geriatrician and PCP may co-manage the client’s care. The geriatrician may do a comprehensive geriatric assessment to determine the client’s current functional and cognitive assessment and to provide improved integrated care for multiple chronic conditions or for common geriatric syndromes, such as incontinence, dementia or memory loss, frailty, failure to thrive, depression, and balance disorders (falls).
Geriatric Nurse Practitioner (GNP) - A GNP is a registered nurse with a master's degree from a nurse practitioner program that specializes in the care of older adults. GNPs are educated to diagnose and manage acute and chronic diseases, taking a holistic approach to meet the medical, psychosocial, and functional needs of older patients. In most states GNPs can prescribe medications. GNPs are board certified through the American Nurses Credentialing Center (ANCC). A geriatric nurse practitioner and a geriatrician may function as a team in co-managing the client’s care along with the PCP.
Home Care Nurse – A registered or licensed practical nurse trained in gerontology who provides skilled nursing services, such as medication management, wound care, monitoring of vital signs, in the client’s home in accordance with the client’s care plan.
Home Health Agency – A Medicare certified agency that provides intermittent care to a client in the home when certain criteria are met. This care is reimbursed by Medicare. The SAH Care Coordinator will coordinate the care with the Home Health Agency as long as services are covered and transition the client to Staying-At-Home services as needed.
Hospital Health Care Team – If the client is hospitalized, the SAH Care Coordinator will coordinate care with the hospital health care team to assure that appropriate information, including the client’s health care goals and wishes is made available to the health care team. The SAH Care Coordinator also will work with the health care team on discharge planning to ensure that the client receives the most appropriate care in the appropriate setting possible with the intent of assisting the client in returning home as quickly as possible.
Nursing Home Team – If the client is placed in a nursing facility as an interim step, prior to discharge to home , the SAH Care Coordinator will coordinate care with the nursing home care team to assure that appropriate information, including the client’s health care goals and wishes is made available to the health care team. The SAH Care Coordinator also will work with the health care team on discharge planning to ensure that the client receives the most appropriate care in the appropriate setting possible with the intent of assisting the client in returning home as quickly as possible.
Personal Care Assistant – A personal care assistant is a nursing aide or a companion who provides assistance with Activities of Daily Living (ADLs) such as ambulating, transferring, bathing, eating, etc. or Instrumental Activities of Daily living (IADLs) such as household chores, grocery shopping, etc.
Pharmacist – A clinical pharmacist may make a home visit if the SAH care coordinator and the SAH Medical Director believe that it will help the client with medication management and medication compliance. A pharmacist from the Staying-At-Home program or the community pharmacist who fills the client’s prescriptions is part of the care team. The SAH Care Coordinator will assure that the pharmacist is aware of the changes in the health care status of the client on an as needed basis.
Primary Care Physician – A trained physician responsible for providing primary ongoing care to the client. The SAH Care Coordinator will assist the client with making appointments and assuring that the client keeps the physician appointment.
Social Worker – A social worker may do an assessment to assist the client with advance care planning, special governmental programs, individual or group therapy to meet psychosocial needs, or to assist with family and care giving situations.
Specialty Physicians - These are physicians who provide specialty care and may include cardiologists, surgeons, ophthalmologists, etc. The SAH Care Coordinator will assist the client by recommending highly qualified specialists in the region and assisting with making appointments as needed.
Therapists – These may include physical and occupational therapists, nutritionists, psychologists and others who may provide care in the client’s home or in their office. The SAH Care Coordinator will assist in recommending the therapists when needed.
Service Levels Offered by Staying-At-Home
Level I Concierge Care
Level II Coordinated Care
Level III Fee for Service Private Duty Nursing Services
Level I: Concierge Care
This level of care is recommended for older clients or their caregivers who can manage care coordination but want the reassurance that they can contact a central information source to receive assistance when needed.
A SAH Concierge who is a community resource specialist knowledgeable in health and support services for older adults is assigned to each client to assist with referrals to health and support services. The SAH concierge will contact the client on a routine basis to determine if any assistance is needed by the client.
A social service professional trained in gerontology will visit the client annually to complete:
- A comprehensive in-home assessment
- Recommendations to help the client maintain independence in his or her own home
- Update the client’s health diary with all his or her health care information
Level II: Coordinated Care
This level of care is recommended for older adults who need assistance with activities of daily living (ADLs) or instrumental activities of daily living (IADLs) or if the caregiver is spending more time in care coordination than in visiting with the client.
At this level of care a social service professional trained in gerontology is assigned to the client. The SAH Care Coordinator provides the following services:
- Performs all the tasks listed under Level I
- Conducts a semi-annual assessment and develops a care plan in partnership with the client
- Visits the client monthly and coordinates care by telephone in between visits
- Coordinates the client’s care needs with all providers, including:
- Making appointments with the physician
- Arranging for transportation and escort services
- Coordinating care following discharge from the hospital, nursing facility or other transitional care situations
- Arranging for trained professional staff to provide personal care services, including:
- Wake-up and tuck-in service or just a sitter to keep you company
- Assistance with bathing, dressing, grooming, and laundry
- Assistance with medication reminders and assistance with medication compliance
- Helping you organize paperwork and manage personal and business correspondence
- Grocery shopping and running errands
- Light Housekeeping
- Arranging for reputable licensed professionals to provide home maintenance services, including:
- Lawn mowing, edging and re seeding, Garden care
- Gutter cleaning, periodic furnace and air conditioner filter changes
- Arranging for the following Clinical and Support Services to be offered at home as indicated in the care plan:
- House Calls by a geriatric nurse practitioner and/or a geriatrician, if the client meets certain specified criteria.
- Medication management, coumadin management, diabetic care, wound care management by a licensed trained nurse
- Professional therapy and counseling services
- Respite care for their caregiver
Level III: Fee for Service Private Duty Nursing
SAH program provides private duty nursing services on a hourly or a bundled fee basis for those clients who may have a short term need for private duty nursing services after a hospitalization or who do not opt for care coordination services. Private duty nursing services range from highly specialized nursing services to assistance with ADLs and IADLs. These services may include:
- I.V. Therapy services, wound care management, diabetes management, medication management and compliance provided by a registered nurse or a Licensed practical nurse specially trained in these services
- Wake-up and tuck-in service
- Bath visits, assistance with ambulating, transferring, eating, dressing, grocery shopping, escorting to health care visits by a personal care assistant
- Companion services to just provide company to the client, read books, read mail, etc. to give respite to the care giver
How Do I Get Started?
Getting started with Staying-At-Home is as simple as 1, 2, 3.
Step 1: Call the Intake Line at 1-866-430-8742 or e-mail us the information to aging@upmc.edu. Based on the initial information, the Intake Specialist will discuss the different levels of care with you and make a recommendation.
Step 2: An SAH Care Coordinator will do an in-home assessment of the client and make a recommendation regarding the level of care needed. The fee for this assessment is waived if the client decides to join the Staying-At-Home program
Step 3: A resource care specialist or a care coordinator is assigned to the client based on the need and a care plan is developed for the client.
Contact Us
Contact the Institute on Aging for
more information or e-mail
us your questions.
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