Home and Community-Based Care
Ensuring that the progress and strides made during a hospital stay are not lost once a patient is discharged is a priority for our Home and Community-Based Care team. With the quality of life and independence of the patient in mind, we provide medical supervision and direction of the team in providing the best care for the patient.
Our physicians provide medical leadership in the UPMC Staying-At-Home program,a client-centered geriatric care coordination program. Client-centered care coordination keeps the patient’s needs in mind by:
- Focusing on "what matters to them" and not "what’s the matter with them"
- Engaging the patient in deciding the direction of care based on his or her capacity to learn, grow, and change;
- Developing a care plan based on his or her strengths, interests, abilities, and capabilities;
- Providing support and peace of mind to family members by helping the patient to live independently
Program of All-Inclusive Care of the Elderly (PACE)
Our physicians provide primary care to participants enrolled in the Community Life program in Allegheny County. We take a holistic view of health care using an interdisciplinary team approach, all working to help our patients maintain self-care ability, remain independent, and age in place.
Our physicians work with the health care team of Community Life to include consultants, social workers, nurses, pharmacists, and physical therapists to address the problems presented by the participants.
Our clinical practice focuses on assessing and optimizing our patient’s function, which includes physical, cognitive, psychological, and social aspects. In turn, this can maximize their self-care ability and quality of life.
The scope of assessment varies depending on the patient’s level of frailty and the ability to do day-to-day activities. We recognize the significant role of the caregiver in caring for the older adult and include caregivers in our assessment and as we develop care plans for our patients.
Our physicians are all faculty members of the Division of Geriatric Medicine, a national center of excellence designated by John A. Hartford Foundation.