Sofia* fled Poland with her family to escape the Holocaust, resettling in Cuba before moving to the United States. For most of her life, she has experienced depression. More recently Sofia was diagnosed with Parkinson’s disease and has begun to show signs of early dementia. At 90, Sofia is no ordinary private care patient—and fortunately, the registered nurse overseeing her case, Marzena P., is no ordinary nurse.
Marzena also happens to be Polish-born and, like Sofia, is fluent in English, Polish, and conversational Spanish. When she visits Sofia to evaluate her medical status and make sure she is receiving the home health care services she needs, they communicate in a blend of all three languages. In her two years attending to Sofia, Marzena has gotten her to pull out old photos and talk about happier times in Cuba and what it was like to raise her two sons. “Sofia is a beautiful person inside and out,” Marzena says. “I call her ‘Babcia,’ which means ‘grandmother’ in Polish.”
Marzena is a clinical manager for Partners in Care’s managed long-term care (MLTC) division, helping to oversee a team of 16 nurses in Manhattan, Brooklyn, and Staten Island, as they make the same type of house calls she does with Sofia. Overall, the division cares for 5,200 patients.
“The care we provide to these plan members really centers around our home health aide service,” Marzena explains. For a member who needs some help with activities of daily living such as grooming, bathing, toileting, and cooking, a home health aide (HHA) may be assigned for just a few hours a day, five to seven days a week. If a member is bedbound or has dementia, then around-the-clock HHA care may be provided. In any of these scenarios, a Partners in Care nurse will visit the plan member as well, to determine exactly what the aide will be doing. An aide’s responsibilities may include specific medical-related tasks, such as measuring blood pressure, weight, and blood glucose; assisting with medication; and addressing any dietary needs. A private care nurse then continues to visit that member regularly to check on their status.
As clinical manager, Marzena supervises these nurses. Her job includes reviewing their field reports and alerting other care providers or the health plan about any changes in patient status that require immediate clinical attention or additional hours of service—something that happens frequently with elder care. “We don’t want things to go on autopilot,” Marzena says. “We’re always assessing to make sure clients are getting appropriate, quality care so they can remain in their homes and age gracefully while living in the community.”
To keep her clinical skills sharp, Marzena also makes a half-dozen or so field visits each week to assess the home care of individual patients like Sofia. During these house calls, Marzena reviews the patient’s medications, making sure the patient, any family caregivers, and their home health aide are aware of possible side effects. She also conducts a home-safety check, evaluates the home health aides to make sure they understand and are following the plan of care, and assesses the client’s physical and psychosocial condition.
Marzena values the relationships with her patients. “One-on-one interaction is important to me. I love the touch, the eye contact, the uniqueness of each situation. There’s nothing like the intimate connection you have when you’re actually seeing that person face-to-face.”
* The patient’s name has been changed for privacy.