Nursing – State Home Care
Registered Nurses perform several functions to support elders staying in their homes and to develop strategies that continue to give people choices in their daily lives.
The nurse performs an in-home assessment to determine if you are in need of personal care. If there is a need the nurse will work with you to develop a plan of care. Bathing, dressing, toileting and grooming are among the possible personal care needs.
The nurse also determines if there is a need for safety equipment or if adaptations should be made to the home prior to the start of personal care.
The nurse reassesses an elder’s personal requirements annually.
CAE (Clinical Assessment & Eligibility)
Beyond the personal care assessments the staff in the nursing department determines a person’s clinical eligibility to enter a skilled nursing facility with Medicaid (MassHealth) as the principal payer of record.
This assessment (called a screening) is based on the state’s guidelines for clinical eligibility. The screening is done in your home prior to entering a nursing facility and is required in order for Medicaid to pay for your nursing facility care.
Our nurse also performs this same evaluation for people who may already be in a nursing home and either need Medicaid to pay for an additional length of stay or for someone who needs to remain in the skilled nursing facility permanently.
As part of Tri-Valley’s effort to assist an elder in making and understanding their choices, we will provide information to the elder and their family, if desired, about alternative community based options and services. These options may meet the elder’s needs and may enable them to remain in the community.
If the nurse‘s screening determines someone is not eligible for a nursing home, Tri-Valley will work with the elder and their family to help develop a community based service plan. Our team of Nurses and Care Managers will work hard to make sure your needs are met and review eligibility for specialized programs at every visit. As your needs change you may need more help, our Nurses will screen for eligibility into programs with more funding for services.
Screenings are also done for elders who want to attend Adult Day Health, and plan to use Medicaid as the payment source.