Lenore Ava Jaffe and Zev Cohen

Small Business Owner

VNSNY Choice FIDA Complete, Medical Management

·Leads the inter-Disciplinary team (IDT) to provide each participant with an individualized, comprehensive care plan designed to maximize and maintain individual’s functional potential and quality of life.
 ·Provides telephonic case management to members.  
 ·New York State three-year demonstration project to develop new model of care for dual eligible (Medicare and Medicaid) nursing home eligible individuals in their homes in the community.
 ·Interviewing, medical history, monitor treatment and social issues, monitor and report response and changes and adverse events to PMD and care team.

Clinical Evaluation Manager

AlphaCare of New York, Inc.

·Chart review and abstraction of new applicant materials. Approve or deny enrollment based on clinical data provided by Field Intake RN, including UAS Health Commerce System assessment, other clinical and social data.
·Determine appropriateness and safety of applicant for this level of care (long-term home- based services for nursing home eligible patients).
·Follow up with Nurse Assessors to resolve, clarify and obtain documentation to answer concerns re: eligibility and safety.

MLTC Quality Review Nurse/via The Judge Group

Amida Care

·Field Nurse Evaluator for a Managed Long Term Program which was a new product in an established Medicaid HIV/AIDS Special Needs plan in NYC.  
·Study and accreditation on the NYSDOH UAS statewide database and assessment protocol.
·Educated the Program Director about MLTC and NYSDOH Medicaid Redesign Team initiatives, issues,  updates and ongoing directives in NYS.
 Studied time frames mandated by NYSDOH for incident, appeals and grievance processes and reporting.

Field Nurse MLTC

Healthfirst

· Telephonic care management services provided to frail, elderly population of nursing home eligible Medicaid clients living in the community. Provide coordination of Medicare and Medicaid covered services
· Responsible for monthly and episodic calls to members and continuous follow up 
· Evaluate medical and home situation and identify issues that require intervention
· Recognize member's medical needs and emergent risks to member safety. Ensure safe transitions from homecare to acute care and appropriate discharge plans from acute care to prevent unnecessary hospital readmission
· Advocate for member
· Educate member and family/caretakers in health promotion, risk reduction and disease/symptom management
· Effective communication and coordination with all caregivers/medical providers, collaborate with managed care team colleagues 
· Continuous reevaluation of effectiveness of member's care plan and mix of services provided

MLTC Nurse Case Manger, Senior Health Partners

Jewish Home Lifecare

· Office based admissions nurse role.
·Gathered collected and analyzed clinical and social data on applicants for sub-acute rehabilitation, using pri instrument received from acute care hospitals. Telephone follow up with acute care team to clarify discharge plan for rehabilitation and query clinical issues pertinent to patient’s readiness for discharge to lower level of care.
· Liaison with family members, patient and health care community
· Coordinate admissions process, ensure safe and appropriate acute care discharge plan 
· Matching of applicants to appropriate services based on assessed medical needs and medical history

Admissions Manhattan Division

•Foundation funded educational intervention/research study designed by the Palliative Care team at Jewish Home and Hospital.
 •One on one instruction re: palliative care principles, with individual certified nursing assistants.  Helped C.N.A.s identify palliative care/advance directive needs of their patients
•Facilitated communication between professional staff and C.N.A.s regarding interventions proposed by   C.N.A
•Counseled and instructed patients and family members regarding end of life issues
•Data collection and documentation of interventions. 
• Reporting of events to Primary Investigator.
 •Evaluate effectiveness of learner outcomes

Effects of Intervention:  
•Project was a success as a new method of introducing palliative care principles to unit teams
•Effective team building intervention that increased interdisciplinary communication
•Professional staff experienced increased respect for the role of the C.N.A. in the Nursing Home setting.
• C.N.A.s experienced increased morale

Palliative Care Project/Study Coordinator, Bronx Division

My goal is always excellence in patient care. I work collaboratively and value a collegial relationship with other health professionals, allied health workers, direct reports, caregivers and of course, the patient.

My background and experience is varied and extensive with an emphasis on program coordination and management, research, and care management.

Member Geriatric Scholars Community (Consortium of New York Geriatric Education Centers).

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