New York State’s CARE Act: New Rules for Hospital Discharge Planning

By Jessica Zwerling, MD, MS

Teresa Santos, MSW, LCSW

“Mom, stop it! You don’t have a paper due! Stop it right now! You’re not in college.” It was 3 a.m., and the woman was trying to convince her 80-year-old mother that her need to hand in a dissertation to the professor was “all in her head.”

“I was standing there, helpless, crying, and all I wanted to do is pick up the phone and call you for help,” she told me days later at a support group that I run at the Montefiore Einstein Center for the Aging Brain for caregivers of people who have Alzheimer’s disease.

The woman knew that she couldn’t call me at 3 a.m., but I knew just the place that could help in those moments: CaringKind’s 24-hour Helpline, for 30 years the lifeline at the other end of the phone for overwhelmed caregivers in New York. The Helpline connects its callers with the resources they need when they need them.

CaringKind describes Rapid Referral as a program “to assist with meeting the non-medical needs of patients and clients with memory loss” and an easy way to link families directly to a CaringKind Helpline specialist by completing a simple, one–page form.”

The Rapid Referral consent form is a prescription of sorts that recommends “medications” — support groups, early stage programs, legal/financial assistance and the like — for people who have been diagnosed with Alzheimer’s disease or other dementias or for their caregivers. It connects them with a wealth of resources and support in hundreds of languages, closing the loop from the point of diagnosis to living with a new normal.

CaringKind’s Rapid Referral program is an essential component of the tapestry of services offered by the Center for the Aging Brain and the Memory Disorders Center in the Bronx. The CAB, as we call it, provides personalized and comprehensive treatment for a range of conditions facing older adults, including, memory loss, dementia, failure to thrive, functional decline, falls, suspected abuse and neglect.

Our multidisciplinary approach to care brings together under one roof the expertise of world-class doctors to provide comprehensive care for illnesses and quality-of-life issues associated with aging. The CAB provides access to a range of medical experts and specialists, including: geriatricians, neuropsychologists, neurologists, social workers, physiatrists, geriatric psychiatrists and care managers. After this multistep evaluation, it is an important component to know we can connect our patients and their caregivers to the programs at CaringKind to help ensure that they have the non-medical support they need.

We apply a compassionate, team-centered approach to caring for loved ones at both Montefiore-Einstein sites, and we try to open doors between our office and the community based resources. CaringKind’s Rapid Referral program is handled like any needed prescription given to a patient. But it’s free, and we follow up to ensure that it’s “filled.”

Caregivers have reported positive experiences with the program. They describe being home, feeling alone and isolated, when their phones ring and a warm, compassionate and skilled professional in the field of dementia holds their hand from the other end of the phone. Whether the call is to provide the caregiver with information about diseases associated with memory loss or mailing a packet of information about long-term care and financial planning or how to apply for Medicaid homecare or the differences between homecare, adult day, and residential programs, it relieves the burden for caregiver of having to remember yet one more task.

And there’s the 24-hour Helpline, too. At her next appointment after she signed the Rapid Response consent form, the caregiver whose mother wanted to submit a dissertation, said that Helpline staff did contact her. She was taught the best strategies to use during her mother’s moments of delusion.

“The next time mom tried to submit her dissertation at 3 a.m., I called the 24-hour Helpline and they guided me through the experience,” she said. No longer alone, she was now able to navigate the complex realities of caring for her mother. A simple, one-page fax allowed us to bridge two worlds and enhance the care of both our patient and her caregiver.

Jessica Zwerling, MD, MS, is a board certified neurologist and neuromuscular specialist. She is currently the Program Director of the newly designated Montefiore-Einstein Center for Excellence in Alzheimer's Disease, the Associate Director of the Center for the Aging Brain, and Director of Clinical Neurology at the NIH funded Einstein Aging Study. She is the Director of the Memory Disorders Center at Blondell Avenue, the Director of the UCNS Geriatric Neurology Fellowship, the head of the Neurodegenerative Clinical Trials Program and the site leader for the “Neurology of Aging” with Montefiore’s participation in the HRSA GWEP grant.

Teresa Santos, MSW, LCSW is certified in Medical Interpretation  and is currently Behavioral Health Care Manager for both the Memory Disorders Center (under the Fan Fox & Leslie R. Samuels Foundation, Inc. grant) and for Montefiore Health System’s Center for the Aging Brain (under NYSDOH’s Centers for Excellence in Alzheimer’s Disease initiative).

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