Your mother needs help. She asked you to accompany her to her primary care doctor visit to talk about fatigue and loss of appetite and you find out that she has fallen a couple of times and didn’t tell you.
She also hasn’t filled her prescriptions and is unsure of the date of her next specialist’s appointment.
Since you live a couple of hours away from her, you try to come up with a solution to help maintain her safety and independence while getting assistance to help her with these challenges.
For the past 30 years, the Visiting Nurse Association of Cape Cod Public Health and Wellness division has provided town nurse support to many seniors needing assistance with medical and community services.
The program provides medication education and assistance, help navigating the healthcare system, education, and home safety assessments for seniors who need extra help and guidance but don’t meet the criteria for the certified division of the VNA.
“The services I provide are different than the traditional certified VNA that everyone knows,” said Lauren Forziati, RN, BSN, the town public health nurse for the VNA of Cape Cod Public Health and Wellness division.
To receive the services of the certified division, such as nursing care, physical therapy, occupational therapy or other disciplines, the patient must be homebound and meet other criteria for services to be covered by Medicare, she said.
The services Forziati provides are financially supported either by the town health or human services departments. The Cape Cod Councils on Aging in 13 of the 15 towns are the primary referral source for town nurse visits with the exception of Sandwich and Barnstable because they have their own town nurses, she said.
She describes her role as a combination of case management, community liaison and social worker.
“Many of the people using this program don’t have anyone,” said Forziati. “They tend to be reclusive, may have psychiatric or mental health issues and sometimes may be reluctant to be compliant with the services I put in place for them.”
She contacts the senior prior to her visit to do an in-depth interview and assessment of their needs before going to visit them in their home. Once she knows what their needs are she will contact their physicians, families, and make referral to services, whether it be transportation, physicians’ visits, medication management, education, and/or referrals to Elder Services of Cape Cod for their many supportive programs in the community.
Forziati described a situation where a physician had contacted her about one of his patients who had been falling a lot. There were some medication discrepancies, but the patient didn’t have a new diagnosis, she hadn’t been hospitalized and he couldn’t deem her appropriate for certified criteria for Medicare. She needed extra help.
“When I went to see her, there was progressive cognitive impairment,” said Forziati. “She lives independently without a lot of supervision. I got her in to see her primary care physician, who she hadn’t seen for six months. She had some labs done, and we’re getting her to see a neurologist for some possible advanced therapies for her cognitive impairment, getting her transportation, Meals on Wheels and a few other things.”
COVID, Isolation and Disparity
“People have become more isolated since COVID-19 due, in part, to lack of caregiver services and also the fear of going out,” said Forziati. “So many have become more de-conditioned and have had no medical attention. Some of these everyday chronic illnesses became acute or chronic with exacerbations that no one really was managing. Some are beyond correction, it’s reactive instead of proactive.”
She is finding that many people want to stay at home at all costs but trying to keep them safe is an ongoing challenge. It requires a lot of monitoring. “I am not out there on a long-term basis so I try to put in as many referrals into place as I can. I have weekly check-ins with the COAs, updating them about patients and who I am seeing so when I am gone, they are still on the radar of the outreach workers.”
Another challenge she has found is disparity of healthcare and support services on the Lower Cape, where she sees the most patients.
“Seniors on the Upper Cape are more connected to their communities or they have a greater accessibility to health, family, friends, or caregivers,” Forziati said. “From Mid-to Lower Cape, (Orleans, Wellfleet, and Provincetown are her most concentrated towns) it is a vastly different population. They are very much more isolated, caregivers are harder to come by, and geographically, they don’t have as many healthcare options available to them, said Forziati.
While Forziati receives most of her referrals through the Councils on Aging, she encourages family members, seniors, caregivers, and providers to call her and discuss if a referral is appropriate.
To reach the VNA Public Health and Wellness office, call 508-957-7423.
