Social worker Kenia A. remembers being surprised when she arrived at the home of a newly assigned patient and found the elderly woman waiting for her outside the front door. “We stood talking for 15 minutes before she finally invited me in,” recalls Kenia, who works for VNSNY Home Care’s Bronx regional office. “As it turned out, I could barely walk in the door. She is a hoarder, and was keeping nine cats in her apartment. There were feces everywhere.”
Unable to find a clean chair to sit on, Kenia conducted her assessment standing up. She educated the patient about available services and then pulled out her phone to begin making referrals—New York City Adult Protective Services, to assist with the hoarding situation, and VNSNY’s Community Mental Health Services to assess the patient’s mental health needs and link her to counseling. She also touched base with her interdisciplinary care team to confirm that the woman would be getting physical therapy visits in addition to home nursing care for her hypertension and diabetes.
Through it all, Kenia was careful to keep her patient informed about each step. “I tell everyone I work with, we’re not here to change you but to help you take good care of yourself, so you can stay safe at home,” she notes.
Kenia relishes the chance to see her clients in their home environment. “You have to go into each home with an open mind and try and understand the patient’s point of view. You see the whole person that way,” she says. “You begin to understand why they’re not taking their insulin, or realize that the reason their adult child isn’t coming around is because the parent is shutting them out. I love what I do because every patient comes with a different dynamic and different challenges. That’s helped me stay committed to this work for the past eighteen years.”
One constant is that she must move swiftly to assess each patient’s needs and figure out what resources and services to connect them with. “Our involvement is short term, so we’ve got to get right on the phone to start making referrals and coordinating services. We may also need to reach out to family members.”
Kenia likes to make some of her follow-up calls in front of her patients to bolster trust. “The key to successful social work is creating that alliance, so that the client knows we are there to assist,” she explains. “As medical social workers, we help our patients and their families adjust to the impact of illness on their daily lives, and help put the appropriate services and supports in place so they can have the best quality of life possible.”
“The people I’m seeing are often very ill. You just have to put the pieces together and try to make things better for them.” When the pieces click, however, the results can be dramatic. Kenia has one patient with a chronic leg wound who kept having her Medicaid deactivated due to a technicality. “It took a lot of advocacy to work that glitch out, but then she was able to enroll in VNSNY CHOICE MLTC, where she’s doing really well. It’s been a real success story.”
A fluent Spanish speaker, she especially loves helping clients learn to navigate a system for themselves. “When I’m with a frail elderly woman who speaks no English and is overwhelmed by paperwork, and I can break everything down for her and make it manageable and obtainable so that she lights up with understanding, it’s a great feeling,” she says. “I write everything in a folder, so they can go back and read it whenever they need to. If I can help my clients become more independent, then I’ve done my job.”
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