OSWEGO, NY — Setting goals and helping others achieve their goals is always rewarding. For former Morningstar Residential Health Care resident David Jones, reaching his goal was not just rewarding, it was life-changing.
Elizabeth Rebello, director of social services at Morningstar, said it is the goal of everyone who works at the facility to do everything in their power to assist every resident and short-term rehabilitation patient in reaching their ultimate goal(s).
“When we care plan (for our residents), we set goals by trying to find out what it is they are looking to do,” Rebello explained. “If something comes up in a discussion with the resident or a family member – whether it is developing more friends, participating in more activities or to get back out into the community – we try to make it happen.”
For David, his goal was to go back to the Pulaski area to live to be with his brother and friends.
“Although he liked living here and had made friends with both staff and other residents, he wanted to be near his family and familiar surroundings,” Rebello said.
“My brother, Davey, had a stroke, he can’t walk and he needs round the clock care,” said Thomas Jones. “He was in Morningstar for five years when I heard about a program that helps get them back into the community.”
Rebello said the Nursing Home Transitional Diversion Waiver, through which people are able to transition back into the community, is a fairly new initiative. Due to the type of stroke he had, Jones was processed through a similar transition program, the Traumatic Brain Injury Medicaid Waiver.
Thanks to this program, along with the support of various local agencies, Morningstar and his family, Jones was able to meet his goal and now resides in an apartment in his hometown of Pulaski.
Kate Budlong, regional resource development specialist with ARISE in Syracuse, said ARISE is the lead agency for the NHTD and TBI transitional programs..
“Typically, a social worker at the nursing home would make the referral for the resident wishing to transition back into the community,” she explained. “Basically, in the case of the TBI waiver, we come out and do initial assessment to see if they are eligible and what services they would require.”
Once ARISE approves them for transition, the person is given a list of agencies to provide the services to make it happen.
“We oversee everything and approve everything, but we do not provide the services,” Budlong said. “For that, we provide the participant with a list of providers for them to choose from, such as Self-Direct Agency, Staff Kings or All Metro Health Care.”
For Jones, his brother said Self-Direct, Inc. was their agent of choice.
Crystal Grau is Jones’ service coordinator with Self-Direct. She said even though David needs 24-hour a day care, he was a good candidate for the transition because he had great family support, especially from his brother.
“Once they are approved, the service coordinator will arrange whatever services the individual needs,” she said. “It can be more than one agency, and as service coordinator, I coordinate between them. It is not left up to the family to have to do all that.”
Grau said even though David was a little nervous at first, he has transitioned nicely and is grateful for what everyone at Morningstar, ARISE, Self-Direct and, of course, his brother to make his wish a reality.
“I continue to meet with the family at least once a month to make sure everything continues to go smoothly for him,” she said. “He is doing great.”
David’s brother concurs.
“Morningstar was very supportive and although Davey was well-provided for there, it is still not the same as being in his own home in his hometown,” he said. “All of his friends are here and can visit him more often than when he was in Oswego. So, it is just better all the way around.”
Jones said as soon as his brother gets his new wheelchair, he will be able to get taken out for walks and he is especially looking forward to taking him to the weekly farmers’ market.
“Its been great, I can’t say enough about Morningstar, Self-Direct and the transitions program,” he added.