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Get to Know Sonya Choudhury, a Long-term Care Nurse Practitioner at our Manhattan Campus

Get to know Sonya Choudhury, a long-term care nurse practitioner at our Manhattan campus, as she reflects on The New Jewish Home’s response to the COVID-19 pandemic and how building meaningful relationships with residents leads to better clinical outcomes.

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Helping Frail Cardiac Patients Get Well, Go Home and Stay Home

Marlene Konopolsky, who runs the Social Work Transitions program on our Westchester campus, provides expert care from the moment patients arrive for heart rehabilitation to three months after they are discharged home. “I’m essentially their care navigator for the next 12 weeks.”

A clinical social worker who has additional training in congestive heart failure, Marlene works with frail, chronically ill patients with various cardiac conditions who were admitted for short-stay rehabilitation. With the goal to reduce emergency room visits and re-hospitalizations, Marlene provides education and monitoring to help stabilize this medically complex group of patients. She has become an invaluable one-stop resource for these cardiac patients and their families, guiding them throughout their stay and during their transition back home.

“I’ll make sure they have all their medication,” Marlene said. “If they need transportation I’ll make those arrangements. I get involved with various agencies if the patient needs Medicaid, counseling services, legal help, advanced directives, or access to doctors.” She’ll even take on housing issues. “If a patient’s condition worsens at home, in most instances, we are able to bring the patient back to our facility instead of the hospital.”

How the Program Works

When patients with cardiac conditions are admitted after a hospitalization, the staff determines whether they are appropriate for the Social Work Transitions program. Marlene is involved in their care plan and makes sure their needs are met. She arranges and plans for their discharge, making sure they get all the equipment they need and coordinates their home care. She makes contact with the patient’s primary care physician as well as the cardiologist to ensure that an appointment is made within a week following discharge. While Marlene previously made home visits; these days she is more likely to drop in via phone or FaceTime.

The Patient Experience

Raymond Piedmont was a Social Work Transitions patient last year. He has been treated at The New Jewish Home’s Westchester campus several times, and his last discharge was in October 2019. “I had been laid up so long I forgot how to walk,” he said. “The people there were absolutely wonderful. Without them I wouldn’t have been able to do the things I’m doing now. I can walk without a cane.”

Marlene was there for him throughout his stay and beyond. “She would pop in once in a while to ask, do you have any questions? Is anything I can do for you? Whenever there was a care team meeting with the doctors, Marlene would be there.”

After Ray’s discharge, Marlene came to his home several times. “She asked specific questions — do you need this? Are you able to do that? Are you getting around? are you climbing stairs? She was assessing my situation, even without me having to say anything.”

Over the past few months, Marlene has worked with post-COVID patients who received rehabilitation therapy. One of her patients, Vinicia Rosario, was recently discharged. “She was with us from the beginning, and she was very attentive,” said Vinizia’s granddaughter, Cindy Hidalgo. “She answered all our questions. Marlene keeps us in the loop about everything in regard to my grandmother’s care. She said, ‘I’m your eyes and ears and voice when the team is meeting, since family members can’t be there.’ She held our hands and guided us through the entire recovery journey.”

Marlene is very accessible to patients and families. They can depend on her if an issue arises. “Families are so overwhelmed when they bring a patient home from the nursing home, it’s reassuring to know they can just pick up the phone and connect with me,” she said.

Just recently, she relates, she discharged a patient on Saturday and readmitted her on Sunday. “I spent a lot of time on the case with the patient’s niece, guiding her through the process of readmission and providing emotional support,” Marlene said.

Even on weekends, patients in the Social Work Transitions Program and their families can count on Marlene to be there for them. Thanks to this unique program, these patients have access to the expertise of a caring social worker whose commitment to them doesn’t end when they leave The New Jewish Home.

Photo: Patient Vinicia Rosario, front row second from the left and Social Worker Marlene Konopolsky to her right with the patient’s care team and family upon discharge home

Enhancing Care Through Deep Knowing

Mrs. L., a resident at Sarah Neuman, The New Jewish Home’s Westchester campus, was visited regularly by her husband. “He came religiously every day to help walk with her and care for her,” according to Miriam Levi, Assistant Administrator. “So it ripped him apart when we closed our doors in March because of COVID-19.” But, thanks to a person-directed care model, adopted six years ago by The New Jewish Home, Mr. L. was able to maintain frequent contact with his wife during the pandemic even though he couldn’t visit like he used to.  “The staff worked out a way he could come to a fence in the garden and see her, and he could call every day and be comforted by the fact that he was talking to someone who really knows his wife — her habits, likes and dislikes. That’s a big plus for residents and families.”

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Making Spiritual Connections During COVID-19

Residents and patients at The New Jewish Home have always appreciated chaplaincy visits. During the pandemic, however, these visits evolved to provide deep emotional and spiritual care to meet the needs of our older adult clients. Each year, in conjunction with the Jewish Theological Seminary, The New Jewish Home helps train chaplains by hosting students in our Clinical Pastoral Education Program (CPE). We are one of the few nursing homes in the country to offer training to chaplain interns, and the only one accredited in New York State by the Association for Clinical Pastoral Education as a training site for this crucial work.

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What’s Next After 51 Days on a Ventilator? A Dedicated Team of Rehabilitation Therapists

Larry Kelly is probably one of the best-known COVID-19 survivors in New York City. Larry, who retired a few years ago as the assistant principal of a high school in Harlem, contracted COVID-19 while performing in a dinner theater in Fair Lawn, NJ. The whole cast of the play got sick. A New York Times profile of Larry, published in July, reported on the 51 days he spent on a ventilator in a drug-induced coma, first at Mount Sinai Morningside and then at Mount Sinai Beth Israel Hospital, before he arrived at The New Jewish Home.

Continue Reading What’s Next After 51 Days on a Ventilator? A Dedicated Team of Rehabilitation Therapists

How We’re Tackling COVID-19: A Conversation With Our Manhattan Medical Director

Dr. Ruth Spinner, our Manhattan medical director, has been expertly leading The New Jewish Home’s system-wide response to the devastating pandemic since February, tracking the disease in Asia before we experienced any cases of COVID-19 at our facilities. She continues to skillfully guide our COVID-19 tasks force, which brings senior leaders, clinicians and administrators across our system together on a daily call where they proactively plan and solve problems, discuss best practices and analyze the latest guidance from the New York State Department of Health and the Centers for Disease Control. Though the worst of the pandemic is now hopefully behind us, Dr. Spinner continues to lead with candor and motivation to provide our clients with outstanding clinical care. We asked Dr. Spinner a few questions about her experience and what sets The New Jewish Home apart.

Continue Reading How We’re Tackling COVID-19: A Conversation With Our Manhattan Medical Director
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