Community Life caring for Mon Valley seniors

By Kristin Emery

No one wants to think about the possibility of having to leave their home as they age. A survey by AARP shows 77% of seniors want to stay in their homes, though 25% of caregivers find it difficult to find the help they need to care for a senior at home. That’s where Community LIFE can help fill the void.

Community LIFE is an all-inclusive program empowering older adults to remain at home while preserving their dignity, independence and quality of life. The organization opened the doors of its Mon Valley Health and Wellness Center in Rostraver in late 2019, just before the onset of the pandemic. “It was COVID, so we did not really get to know the community, and the community did not get to know us,” says Community LIFE president Fatemeh Hashtroudi. Community LIFE is headquartered in Pittsburgh and operates seven locations across Allegheny, Somerset and Bedford Counties, in addition to the Rostraver Health and Wellness Center at 2115 Trebella Circle.

How do they help?

Community LIFE is part of the Program of All-Inclusive Care for the Elderly, an optional benefit under Medicare and Medicaid that focuses entirely on older people who are frail enough to meet state standards for nursing home care. The program brings together all the medical and social services needed for someone who otherwise might be in a nursing home. Hashtroudi describes Community LIFE’s services as a nursing home replacement program. “It is a program that is meant to provide support for people who would like to stay at home,” she explains. “We manage care for participants who – without our help – would have been at a nursing home. We help them to stay at home and be closer with their families and caregivers.”

The program includes the Health and Wellness Centers, medical care, in-home care and transportation. Most beneficiaries in the plan are eligible to receive services under both the Medicare and Medicaid programs. Whether it’s assistance with laundry or physical therapy to recover from a fall, Community LIFE provides caregiving at home and at their Rostraver location.

“The goal is to help our participants stay at home,” says Hashtroudi. “That is what we do. And it’s a very comprehensive care management program making sure that the participants have meals to eat, have medications, that they get to their doctor’s appointment whether it’s at the hospital or the doctor’s office. We make sure all of that happens for our participants.”

Coordination of care

Nobody wants to face the prospect of going into a facility or having your loved one at a place other than home, yet it can be difficult and expensive to manage care with work and family. “This is very helpful to the families, and also we help with family support,” Hashtroudi adds. “We have social workers, behavioral health care managers, we have people in our palliative care departments, so we do provide families with ongoing support.” That includes their respite program that accommodates participants with care for up to 48 hours if family or caregivers need help or to be away for a few days.

“Our services have that component of family caregivers in mind and family caregiver burnout in mind. We do everything that we can to reduce the burden on the family members as well.”

The first step is to determine that the participant is at the nursing home level of care. If eligible, Community LIFE will work with the participant, family and caregivers and do an at-home visit to assess what that person needs to stay at home. “We have a team of 11 people … doctors, social workers, dietitians, physical therapists, occupational therapists … and we assess the home,” Hashtroudi says. “We say, okay, what is it that they need in order to stay at home? Maybe they need a ramp, maybe they need a stair glide, maybe they need nothing. Maybe they need to come to our adult day center two or three times a week.” Some clients need assistance with laundry, preparing meals, cleaning or taking medications. “Once we do that assessment, we design a care plan for the participant, and then every six months, we evaluate that care plan to make sure we still are meeting the needs of the participant and the family members.”

The Mon Valley Health and Wellness Center includes three major components. “One is an adult day center where our participants can socialize, have a hot meal, take a shower, participate in activities,” says Hashtroudi. The second component includes a physical and occupational therapy suite, including rehabilitation facilities. The third component is the medical suite and clinic housing doctors, nurse practitioners and staff. “So instead of going to a doctor, our doctors become their primary care physicians. Whether it’s something chronic like heart failure, COPD or diabetes, we manage that. If it’s something acute, our clinic nurses go to the participants’ homes to check on them to make sure that they’re taking their medication and that they have food and their home is clean.” Community LIFE participants also receive transportation, medications and vaccinations for no additional copayments. She stresses the convenience and importance of coordinating care in one place. “That is that is really the important piece because with seniors, they go to different doctors and they go to different places,” she explains. “One doctor writes a prescription, and another doctor writes a different prescription. Here, that is all coordinated, and the participant receives one-stop care.”

To be eligible, a person must be 55 or older, live in the service area, be able to live safely in the community and be certified as eligible for nursing home care by the state. Enrollment is voluntary, and once enrolled, Community LIFE becomes the provider of all Medicare and Medicaid covered services, as well as any other items or medical, social or rehabilitation services an enrollee needs. For more information, call 1-866419-1693 or visit commlife.org.