For High-Risk Residents
Fair Share Support Services is working in collaboration with the Rowan Medical School to assess the health and well being of our residents. We conduct comprehensive health, psychosocial and functional assessments on the senior and disabled residents who live in the Northgate II high-rise building.
We have approximately 90 residents who have been identified as frequent emergency room utilizers. These residents have multiple chronic diseases and they also experience the highest number of hospital stays. To improve the health and well being of these residents, Fair Share Support Services offers the following programs:
Assisted Living Program
- Agreement executed with Caring, Inc., an experienced assisted living provider in South Jersey
- Targeted to residents with multiple chronic illnesses and who need assistance with at least 3 ADLS
- AL Staff assist residents during different times of the day according to needs.
- On-call 24-hour nursing support
- Will include an onsite social day program
- Caring, Inc.’s state license for NGII is approved
Post-hospitalization Care Coordination (with CCHP)
- Implementation Date: November 1, 2013
- Imbeds onsite CCHP nurses, medical fellows, community health worker at Northgate II.
- Targets high hospital utilizers.
- Provides intensive care coordination over a 1-2 week period to ensure post-hospitalization medical needs are met.
- PCP visit within 7 days
- Medication Reconciliation
- Ensures close collaboration between CCHP care coordination staff and NGII social services staff.
- Bi-weekly Care Coordination meetings
- “Hand-off” of patient to social services staff after intervention
- Involvement of Community Health Worker is essential
- Limited access to HIE for Northgate II Social Services Staff