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Healthcare

Nira Monero is a Clinical Manager. She manages the RNs who care for SeniorBridge patients. In her 12 years of home care experience, she has helped many patients struggling with multiple chronic conditions. Heart disease, however, causes 1 out of every 4 deaths in the U.S. (CDC). Therefore, we focused our conversation with her on delivering home care for a person with cardiovascular disease.

Q

“Cardiovascular disease” is a large category of conditions. What has been your main area of experience?

A

We often deal with elderly heart patients. Many times it’s congestive heart failure, atrial fibrillation, or another condition. But our patients are already past the onset, so we’re in the process of creating a plan that each patient needs while being cared for at home, including diuretics and mental health conditions that often come with heart problems, specifically depression.

Q

How do you manage care when there are other providers involved?

A

Orders from the cardiologist are shared with the primary care physician and we assess the patient in their home environment. We facilitate and explain the patient’s plan to our home care providers, keep an eye on vitals, and set up medications, diet, and exercise. If we need to add a service, like wound care, that’s part of our assessment.

“Trust is so important, especially to elderly people who don’t always know what’s happening.”

Q

What about patients who are struggling emotionally? How do you provide care for someone who doesn’t want it?

A

It’s complex. We’re dealing with elderly people so many issues can arise. Patients may be depressed. Some resist care. Some hate any change in their regimen, and naturally they’re not comfortable when there are new faces in the house. So we assess emotional states and the RN considers whether a social worker can help. It’s also important to match the personality of the care team to the patient. Some of our caregivers are quiet, others are more vocal. We can tell during the assessment what type of caregiver will be the best fit.

Q

How do you build trust with the patient?

A

It’s a day-by-day process. But the RN has a steady presence, explaining the care plan to the patient and family, helping to identify the appropriate aides, and educating all caregivers - especially on medications. We communicate with all responsible parties and follow up. Trust is so important, especially to elderly people who don’t always understand what’s happening. But in a short time they begin to see that we’re there to make sure they have the best care at home.

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