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Our Services

Our Interdisciplinary Team

At Mount Sinai Eldercare, our Interdisciplinary Team consists of a group of dedicated and experienced health care professionals who are committed to helping our members thrive — physically, mentally, and emotionally. At Mount Sinai Eldercare, our health plan members are recognized as “participants,” as they “participate” in all aspects of their care.

Participants and caregivers work alongside the Interdisciplinary Team to create a complete, personalized care plan designed around the participants’ medical, physical, and social needs. Our Interdisciplinary Team coordinates PACE services that include all Medicare and Medicaid benefits and other needed services, so our participants can continue living in their own homes for as long as possible.

Mount Sinai Eldercare’s team of health care professionals help participants make health care decisions. Our experienced team members are experts in caring for frail older adults.

PACE interdisciplinary team

The Mount Sinai Eldercare Interdisciplinary Team meets regularly with participants to ensure their comprehensive medical and social needs are not only being met, but are also adjusted over time and after any changes in their health care status. Behind the scenes, the team meets daily to discuss changes in our participants’ medical, functional, and psychosocial status — always focusing on the goal of keeping our participants at home so they do not have to be in hospitals and nursing homes.

Center Manager — is there to help both our participants and our care team coordinate and manage their daily needs. The center manager will check on our participants to make sure they are safe and address any issues that may arise.

Home Care Coordinator — visits participants in their homes to assess what their needs are and make sure they receive necessary care. The individual care plan will include the needed home care services, which can include home nursing visits; home physical, occupational, and/or therapy care; and certified nursing assistants to help with bathing, personal care, companionship, light housekeeping and respite care.

Medical Director/Primary Care Physician — the clinical leader at the Mount Sinai Eldercare Center; since doctors are located on-site, they are able to keep a close eye on participants’ health and better focus on preventive care.

Nursing Assistant — helps Mount Sinai Eldercare Center participants to participate at the highest level possible, providing one-on-one assistance when needed with meals, activities, personal care, and toileting.

Occupational Therapist —works with participants to improve their level of independence with Activities of Daily Living (ADL) — such as dressing, bathing, grooming, and energy conservation — helping to keep them healthy and safe at home.

Physical Therapist —helps participants improve or maintain their mobility by focusing on evaluating their ability to walk, climb up and down stairs, and go out into the community — like going to the store and having fun.

Recreation Therapist — coordinates services and designs activities, such as art therapy, music therapy, and dance and movement therapy, for participants on a monthly basis; the activities consider the cultural diversity and unique preferences of our participants (a sample monthly activity calendar can be found here).

Registered Dietitian — provides appropriate nutritional interventions based on each participants care plan, which includes helping them manage their diabetes, hypertension, high cholesterol, and their weight. Mount Sinai Eldercare Center dietitians can provide nutritional counseling and answer any other questions.

Registered Nurse — on-site at the Mount Sinai Eldercare Center to treat participants who are not feeling well or if the team sees a change in their condition, which helps prevent hospital and urgent care visits.

Social Worker — key member of the team who provides emotional support, counseling, and referrals to both the participants and their families/caregivers; conducts support groups; and routinely meets with participants and families/caregivers to address any issues that may arise.

Transportation Coordinator/Driver — pick up and transport participants safely and on time to all approved medical appointments and to the Mount Sinai Eldercare Center.

Eldercare Services

Mount Sinai Eldercare’s goal is to keep our participants as active and independent as possible, living their best lives at home. The program’s Interdisciplinary Team accomplishes this goal by working alongside our participants and their family/caregivers, creating individualized care plans that cover all medically necessary services, including the services listed below.

Mount Sinai Eldercare is much more than adult day care; it is health and wellness care as well as care for the soul. The Mount Sinai Eldercare Day Health Center is where your friends are, it is where the fun is happening, and it is where our participants and caregivers access many of our PACE services. Our recreation therapists create a calendar every month with social programs that can help participants enrich their quality of life and achieve a balanced social life. Activities may include, but are not limited to, listening to music, playing games, watching movies, exercising, creating art, enjoying holiday parties, and much more!

Companionship, meaningful activities, and daily nutrition are so important for seniors. Mount Sinai Eldercare Day Health Center is designed to make seniors feel safe and valued, while providing essential care and nourishment for the body and mind.

For the convenience of our participants and caregivers, the Mount Sinai Eldercare Day Health Center is open Monday through Friday, 8 a.m. to 5 p.m. Transportation will be coordinated to and from the center by our transportation team, and each participant’s individualized care plan will determine the frequency of their visits to the center.

Our primary care physicians, nurses, and nurse practitioners are available Monday through Friday, 8 a.m. to 5 p.m., at Mount Sinai Eldercare Center’s clinic. In addition, they are on call 24 hours a day, 7 days a week. The clinic is equipped to handle minor symptoms — such as fever, headaches, body aches, and pains — and our medical staff is able to administer specialized treatments and interventions, including wound care and IV therapy. At Mount Sinai Eldercare, we know receiving the proper care when needed is critical to the health and wellness of our participants and their ability to continue living at home rather than in a nursing home. Transportation is provided from each participant’s front door to the center, making access to essential health care services easy on our participants and their families/caregivers.

Our board-certified physicians are highly experienced in the care of the elderly. They work to develop, monitor, and supervise each participant’s medical care and treatment plan and work closely with specialty medical physicians in the Mount Sinai Eldercare network. These specialties include optometry, audiology, dentistry, podiatry, cardiology, pulmonology, rheumatology, and others.

The Mount Sinai Eldercare program covers all approved X-Ray, MRI, CT, mammogram, and any other imaging that is medically necessary. All laboratory services are covered once they are ordered by the participant’s Mount Sinai Eldercare physician. They can be completed at Mount Sinai Eldercare Center’s clinic, at home, or in an outpatient laboratory.

Our Interdisciplinary Team meets regularly to review participants’ care plans and makes changes when necessary. Eldercare is there to coordinate and manage the health care needs of our participants, as this can be a very difficult and confusing task for seniors and their families/caregivers.

We believe preventive care services are essential in maintaining the health and independence of our participants. Therefore, preventive care is included in each participant’s care plan. Our medical team strives to prevent problems from occurring by identifying them early and working together with the Interdisciplinary Team to create individualized care plan interventions to help our participants live longer, healthier, and more satisfying lives.

Preventive screenings may include annual physicals and a variety of screenings, including breast cancer, colorectal cancer, cholesterol, high blood pressure, and osteoporosis. At Mount Sinai Eldercare, preventive care also includes annual eye exams, hearing tests, and dental checkups. All of our participants have access to recommended vaccinations that include COVID-19, influenza, shingles, and pneumonia.

With Mount Sinai Eldercare, a team of health care professionals works with each participant and their caregivers to ensure they get the proper coordinated care. The Mount Sinai Eldercare physicians, nurses, and clinic staff work to get to know each participant as an individual, not just provide their medical care, which improves their overall well-being. In addition to Mount Sinai Eldercare primary care physicians, we have a comprehensive network of highly trained specialty physicians right in the neighborhood.

This network is comprised of locally recognized experts in their field of medicine, many of whom are Mount Sinai physicians. Medical experts include audiologists, dentists, optometrists, podiatrists, psychologists, cardiologists, urologists, pulmonologists, and many more. At Mount Sinai Eldercare, we consider caring for our participants’ health as a privilege. That is why we have put a great deal of care and consideration into selecting the providers in our network. Only the best will do for our participants!

If a participant needs to see a specialist, all appointments are handled through Mount Sinai Eldercare and approved by the Interdisciplinary Team. Transportation to and from approved medical appointments is coordinated by the program’s transportation team. Remember, the medical team is available 24/7 to provide emergency support. For medical emergencies that occur after regular business hours, a Mount Sinai Eldercare nurse and physician are available to assist.

The aging process sometimes causes our bodies to encounter physical challenges we never expected. If you are experiencing a physical obstacle because of aging, injury, surgery, or illness, the experienced professionals at Mount Sinai Eldercare can help you reach your maximum independence, so you can remain living at home.

To meet the goals set in each participant’s individualized care plan, their rehabilitation progress is monitored carefully. Our experienced therapists serve our participants in both the Day Health Center and in the comfort of their homes.

Mount Sinai Eldercare’s comprehensive rehabilitation services include the following:

  • Physical therapy
  • Occupational therapy
  • Speech therapy
  • Respiratory therapy
  • Medical equipment (such as walkers, canes, or wheelchairs, as medically necessary)

Each Mount Sinai Eldercare participant receives annual evaluations by physical and occupational therapists, or more often as determined by their individualized care plan. Ongoing therapy helps participants with activities of daily living so they can remain independent and living at home.

Many seniors need help navigating their physical and mental health, especially when family members live far away. Mount Sinai Eldercare’s social work services provide participants with the support they need while giving them the independence they want.

Master’s-level social workers are vital members of the Interdisciplinary Team, and each participant is introduced to their social worker once enrolled in the Mount Sinai Eldercare PACE program. The social worker is a true advocate for the participants, ensuring their voices are heard and needs are met.

Mount Sinai Eldercare social workers can help with the following:

  • Understand how PACE works and how to access services
  • Communicate with family members/caregivers
  • Assessment of medical, social, psychosocial, and spiritual needs
  • Mental health issues, including individual and family counseling
  • Assistance with community support (food, finances, and housing)
  • Navigate Social Security, Social Security Disability Insurance, Supplemental Security Income (SSI), and Medicaid

Our compassionate social workers have years of experience with helping seniors live their best lives. Our participants set the parameters, and we provide all the assistance necessary to help our participants maintain an independent lifestyle.

To manage multiple health conditions, many seniors have to take several medications. Taking those medications correctly is an important part of maintaining good health and avoiding unnecessary hospitalizations.

Once enrolled in Mount Sinai Eldercare, all medications are not only provided by the program, but all medication needs are coordinated and managed by a Mount Sinai Eldercare physician. Participants also receive the added benefit of a medication therapy management program. A geriatric-certified pharmacist works alongside the Mount Sinai Eldercare medical team to provide clinical consultation 24/7.

We understand that managing medications when there are multiple prescriptions involved can be extremely difficult. That is why our program includes custom medication packaging with easy-to-follow instructions — and in multiple languages if needed. The medications are delivered directly to a participant’s home.

At Mount Sinai Eldercare, our goal is to help our participants remain at home or in the community for as long as possible. Home care plays a key role in helping our participants keep their independence. We offer both health-related and supportive services for the participants. Participants and their families/caregivers work together with the home care coordinator and the Interdisciplinary Team to create an individualized care plan that can include home care services.

Health-related services may include the following:

  • Medication management
  • Incontinence care (such as ostomies and catheters)
  • Wound care
  • In-home injections and blood draws
  • Physical, occupational, and speech therapy

We understand that sometimes caregivers and family members need help in caring for their loved ones, as it can be challenging to balance work, family, and caregiving responsibilities. Mount Sinai Eldercare delivers care and supports caregivers differently than other programs. We partner with the caregivers to help coordinate all necessary care and services, including in-home services. Delivering the expertise and help necessary to support caregivers is a fundamental part of the Mount Sinai Eldercare PACE program.

Supportive services may include the following:

  • Assistance with dressing, toileting, showering, or bathing and grooming
  • Respite care
  • Light housekeeping, laundry, and related chores
  • Personal Emergency Response System (PERS)

Mount Sinai Eldercare recognizes that nutritional needs change as we age, and it can be hard to make sense of the changes. That is why Mount Sinai Eldercare has registered dietitians on the Interdisciplinary Team. The registered dietitians provide nutritional counseling and diet planning as part of the individualized care plan to our participants and their caregivers to help them understand and manage nutritional needs.

Nutritional deficiencies are common among seniors. Our team of providers work together to address any deficiencies and make diet adjustments accordingly. Meals that are nutritious and taste good are served daily in the Day Health Center and can be delivered to a participant’s home when included in the plan of care.

All-inclusive care looks at not only the medical and social needs of seniors, it also includes any approved medical equipment and/or medical supplies needed to carry out the individualized care plans. The Interdisciplinary Team completes assessments and evaluations of our participants in their homes as well as in our center. These assessments oftentimes identify safety risks that can be reduced or eliminated with the use of medical equipment like walkers, canes, wheelchairs, and hospital beds.

Medical equipment may be a short- or long-term need, and both are covered under the Mount Sinai Eldercare plan once approved by the Interdisciplinary Team. Medical supplies needed for the recovery of an injury or surgery, as well as incontinence supplies, can all be part of the individualized care plan of our participants.

The Interdisciplinary Team will oversee the ordering and delivering process of needed equipment and supplies, taking this worry away from our participants and caregivers. That way, they can concentrate on what is most important — living their best lives.

At Mount Sinai Eldercare, we understand the frustration and isolation that seniors feel when they are no longer able to drive. Caregivers can also be overwhelmed with the additional responsibilities of transporting loved ones to medical appointments, pharmacies, and other health-related locations. Our participants receive transportation to and from the Mount Sinai Eldercare Center as well as to medical appointments.

Eldercare drivers do not just pull up to the front of a participant’s home and wait. The drivers go up to the front door and assist the participant to the vehicle. If a participant is in a wheelchair, we provide a state-approved, strapped-down/locked-in method that keeps the wheelchair securely in the vehicle. Assistance is provided for participants using a walker, oxygen, or other medical devices.

Our drivers all have excellent driving records and have passed a rigorous training program that prepares them for all situations they may face on the road. At Mount Sinai Eldercare, our courteous and skilled transportation team members are ready to help our participants access the care they need by providing door-to-door service.

We believe preventive care services are essential in maintaining the health and independence of our participants, and we include preventive care in each participant’s care plan. Our medical team strives to prevent problems from occurring by identifying them early and working together with the Interdisciplinary Team to create individualized care plan interventions to help our participants live longer, healthier, and more satisfying lives.

However, we recognize that emergency services and hospital care may be required during an acute episode. When emergent situations arise, rest assured Mount Sinai Eldercare will be in full communication with the medical facility ensuring your past and current medical history are on hand, overseeing the care provided and working with the hospital to transition you back home as quickly and as safely as possible. In most cases, care will be provided by Mount Sinai Medical Center or one of its free standing Emergency Rooms. Participants do not need prior authorization to access emergency services.

In situations when your care plan requires short-term rehabilitation after surgery or more extensive nursing care than received at home, Mount Sinai will coordinate a short-term stay at one of its in-network nursing facilities. The Interdisciplinary Team will be in close communication with the nursing home and will coordinate your transition back home.

In the event the aging process or medical complications require care that is too extensive to provide long-term at home, the Eldercare Team will transition the participant to a nursing home in their network that meets participant and caregiver needs. Mount Sinai Eldercare will continue as your health plan and oversee the care provided by the facility.

NOTE: Mount Sinai Eldercare participants must receive all of their health care services, including primary care and specialty physician services (except for emergency services), from Mount Sinai Eldercare or a person or company authorized by Mount Sinai Eldercare. Participants may be fully and personally liable for the cost of unauthorized or out-of-PACE program agreement services.

Page Last Updated 7/12/2023

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