HFNJ Grant Expands Team-Based Care for Essex County Seniors at Zufall Health

Zufall Health has expanded care for vulnerable Essex County seniors, courtesy of a generous award from the Healthcare Foundation of New Jersey (HFNJ). The $120,000 grant from HFNJ supports our expansion of team-based medical, dental, behavioral, and supportive services to people 65-plus in and around our West Orange office.

Seniors have an increased risk of chronic and communicable diseases, are more susceptible to social isolation, and are more likely to have difficulty navigating our complex health care system. Patients in this age group who have low incomes and are uninsured/underinsured experience these challenges at greater levels.

Thanks to HFNJ, Zufall has formed a new health care team to better serve this especially vulnerable subset of seniors. The team consists of a geriatric nurse practitioner, nurse case manager, clinical pharmacist, and outreach worker. Team-based care—a primary care delivery model in which patient needs are addressed by multiple providers who work collaboratively—expands access to care and improve health incomes for populations with complex health and social needs.

The four health care professionals will work in tandem to:

• Identify eligible participants, both from our established patient population and from within the community during outreach activities;
• Support patients’ health care system navigation, particularly through transition periods such as hospital discharge;
• Develop individual care plans that include annual physicals and referrals to specialists;
• Perform hearing and vision screenings;
• Identify and mitigate barriers to care;
• Review and reconcile medications and help patients manage regimens; and
• Provide health education classes addressing topics such as hearing, vision, medication safety, falls prevention, improving social connection, and chair exercises.

“Through a team-based approach, we will be able to build relationships with our seniors to provide personalized, preventative, and comprehensive geriatric care,” said Kathleen Felezzola, RN, registered nurse and Zufall’s director of nursing, who manages the program. “Ultimately, we hope to prevent complications caused by chronic illness, decrease the need for hospitalization, keep our seniors in their communities, and give them the opportunity to remain self-sufficient.”

The expanded services coincide with the opening of Zufall’s new, 15,000-square-foot West Orange facility at 49 Mount Pleasant Avenue later this year. Located near several senior public housing residences, the new building will provide ample, accessible space for participants to receive care.

HFNJ is a grantmaking organization committed to reducing health disparities and improving access to care in the greater Newark area and the Jewish community of Greater MetroWest NJ. Founded by the Jewish community, HFNJ is guided by the qualities of tzedakah (charity and righteousness) and tikkun olam (repairing the world).