Senior Services

ElderWell

HeartWell

LifeLine Personal Security System

OASIS Education Center

Potomac Home Health Care

Suburban Hospital’s Community Home Care Management Program, for those aged 65 or older, strives to enable individuals to continue to live independently at home by arranging for their safety and care. Suburban’s program is the only hospital-based, geriatric-care management service in the greater Washington area.

Based on a medical model, the Community Home Care Management team consists of a registered nurse and a licensed clinical social worker. This team helps older individuals, and their caregivers, access information about aging and community resources, develop effective problem solving techniques, and set achievable goals.

The team provides an in-home evaluation and develops an individualized home care plan designed to save time, energy and financial resources. The team uses its knowledge and awareness of the aging process and experience with community resources to develop an optimal plan that extends beyond the involvement of family caregivers to the primary physician, home health agencies, support groups, church/synagogue and public/private community resources.

Suburban’s Community Home Care Management services can help you obtain, coordinate and monitor a broad range of in-home services, including:

• Home health aides
• Transportation
• Housekeeping
• Personal care
• Meal preparation
• Referral for financial and legal advice
• Ongoing social work consults
• Health monitoring of chronic diseases

Suburban’s Community Home Care Management Program can also provide:

• In-home psychotherapy or counseling for the older person and family caregivers,
• Consultation with the primary physician,
• Advocacy for the individual in dealing with bureaucracy and red tape,
• Medication management and chronic illness monitoring,
• Home visits to ensure care plan implementation and adjustment,
• Tests and vaccine administration when ordered by the nurse practitioner,
• Assistance with long-distance care giving by helping to identify problems and find supportive resources, and
• Assistance with assisted living or nursing home placement.

ElderWell

Suburban Hospital is pleased to provide an innovative, chronic disease management program called ElderWell. The program is focused on enhancing wellness and quality of life for those over the age of 65 with congestive heart failure and diabetes associated with cardiovascular disease. The goals of ElderWell are to reduce hospitalization and, when the patient must be hospitalized, to reduce the length of the hospital stay. The ElderWell program offers visits by a registered nurse to patients in their homes. The nurse instructs the patients and their families about the disease process, and symptom recognition and management.

The ElderWell nurse, also called a care manager, is responsible for assessing the patient’s health and developing an individualized care plan. The nurse works in close collaboration with the patient’s physician, and her role does not take the place of medical advice and care by the physician. The nurse evaluates medications and helps manage blood pressure, diet, exercise, and transportation issues, supervises prescription refills, and coordinates follow-up physician visits. The nurse/care manager also helps to coordinate other needed services such as home health aides or meal delivery. The nurse is available by phone Monday through Friday for questions and, if necessary, can often visit the same day. Any extra visits or telephone calls do not change the monthly fee. For more information about ElderWell services, please call 301.896.6500.

HeartWell

HeartWell is a free chronic-diseasemanagement program designed to teach individuals with diabetes and cardiovascular disease how to manage their symptoms and disease. The program focuses on education concerning early disease symptom recognition, symptom management, medication, diet, and lifestyle changes. The program’s goals are to reduce the frequency of hospital admissions due to cardiovascular disease and to help the participant maintain as high a level of functioning as possible.

HeartWell, which is generously funded by the Suburban Hospital Foundation, is targeted to an underserved senior population and there is no charge for the services provided by the registered nurse. Eligible persons are seen by a nurse at the Holiday Park Senior Center in Wheaton (Monday – Thursday), Longbranch Senior Center in Takoma Park (Tuesday), Margaret Schweinhaut Senior Center in Silver Spring (Thursday), Rockville Senior Center (Monday, Wednesday and Friday), and Gaithersburg Senior Center (Friday). The program also sponsors a variety of classes at specific senior centers such as nutrition classes, gait and balance screenings, Tai Chi and weight training classes. Program participants can be self referred, referred by a physician, family member, or any staff member at the Senior Center. For more information about HeartWell services, please call 301.896.6500.

Criteria for admission to the HeartWell program are the following:

• Age 65 or over
• Must have a primary care physician
• Must have a diagnosis of cardiovascular disease and/or diabetes
• Must consent to allow the nurse to share health information with the individual’s physician
• Must agree to inform the nurse about any hospitalization and the length of stay

Financial Information

Care Management

• There is an Initial assessment fee for an individual.
• Additional services are billed according to time and service provided.
• Individuals who meet certain medical criteria are eligible for coverage under Medicare Part B for social work.
• Coverage from secondary insurance is dependent on the person's specific policy.
• Program costs may also be covered under Long-Term Care Insurance with a case management benefit.

ElderWell

The cost of the ElderWell program is $200 per month. The cost is not covered under Medicare Part B, HMO’s or most third-party insurance, although some third-party insurance companies will provide partial reimbursement on a case-bycase basis. The cost of the program may also be covered under Long-Term Care Insurance that has a case-management benefit. A limited number of subsidies are available.

HeartWell

The HeartWell program is free.

For more information about Community Home Care Management, ElderWell or HeartWell services, please call 301.896.6500.