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An isolated elderly widow, who has diabetes, depression and other health problems, is drifting toward a nursing home. A nurse helps her manage her disease, gain a new sense of purpose, make friends at a Brooklyn adult day center and remain at home.
A man in his 80s, who has Alzheimer's disease and needs oxygen, is living in a home without electricity. A nurse helps return electricity to his Bronx home and finds other social-service help so he can remain safely in his home.
 Those are just two examples of many instances in which nurses in Metropolitan Jewish Health System's HomeFirst program are making a difference in the lives of their patients.
HomeFirst is a managed long-term care plan designed for Medicaid-eligible residents in New York City with chronic or disabling conditions. The program currently provides services for more than 3,200 members in the five boroughs.
"We match each member with a nurse health partner," said Holly Pizza, BSN, RN, director of patient services at HomeFirst.
Nurses assess members to make sure "whatever needs they have are met," Pizza said, "or if we don't provide those services, how we can reach out and make sure they get those services."
Nurse Health Partners
Jeanne Dowd, BSN, RN, and Sandra Anthony, BSN, RN, coordinate home-care needs so members can remain independent and out of nursing homes. As nurse health partners, they help access practical help patients may not know they are eligible for, like food stamps, phone and utilities subsidies, housing aid and assistance with Medicaid recertification.
Nurse health partners help with communication needs, too. Anthony, one of Metropolitan's 2006 Most Valuable Employees of the Year, speaks Spanish, along with English. HomeFirst usually can pair patients with a nurse who speaks their language - whether it's Russian, Chinese or a variety of other languages.
A multilingual task force helps HomeFirst nurses "develop a close bond with our members," Pizza said, "at least this is what our members tell us. We are very consistent with our members - meaning our nurses and members stay together. We don't switch around. If [patients] didn't believe in and trust us, we wouldn't be able to accomplish some of the things we do."
That certainly was the case with the reluctant widow who now attends the adult day health center three times a week.
"We had a relationship with her she trusted," said Dowd, who before joining HomeFirst, worked at Metropolitan's Menorah Home and Hospital, a 310-bed skilled nursing home facility.
Collaborative Efforts
As its name implies, the main focus of HomeFirst is to help patients remain in their homes, "which is their security," Pizza said. 
"We do this collaboratively by working with the physicians and others to make sure [patients] stay in their homes as long as they can," she said. "If they age out of the program, and can't stay in their home safely, then we refer them to one of our skilled nursing facilities (SNFs)."
As a participating agency of Metropolitan, the 9-year-old HomeFirst program has access to a 102-year-old organization which also includes hospice, palliative care, skilled nursing facilities, home care and two adult day health centers, which use a medical model of care.
Dowd and Anthony may coordinate with one of Metropolitan's wound specialists, for instance, to heal a patient's wound.
"If [the nurse health partner] refers a patient to one of our skilled nursing facilities, that doesn't mean they have to stay in there forever," Pizza said. "If members get better, we can take them back into the community."
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