At the Core of Our Care Teams: Bay Cove’s Nurses
Bay Cove Nurse Manager Mona Ojugbana with George
Bay Cove’s continuum of programs and services for people living with mental illness, developmental disabilities, substance use disorders and/or homelessness provide significant support in everything from living independently and acquiring employment skills, to transitioning from homelessness to permanent housing and receiving behavioral health counseling. We work each day to offer those we serve in our programs a solid foundation from which they can build the full rich lives they desire. However, a critical component of that foundation is physical health—without that, all the other challenges in life become that much harder to face.
Our agency’s talented nursing and medical staff serve individuals throughout our more than 170 day, residential and community outreach programs, dealing with the full gamut of physical issues—from simple wound care and assistance with daily medications, all the way up to ongoing and serious medical ailments. While not assuming the role of primary care providers, our nurses are regular presences in the lives of those we serve, and play a critical role in helping stabilize and maintain individuals’ physical health.
“Our nursing staff are vital resources for those we serve,” says Dr. Robert Diener, Bay Cove’s Chief Medical Officer. “In many of our programs, our nurses are the frontline workers who track the health conditions of those we serve; help educate clients about their health issues and encourage their adherence to treatment plans; and coordinate with program staff, outside providers and the guardians and families of those we serve—keeping everybody in the loop and aware of individuals’ needs.”
In addition to this, residents of Bay Cove’s Group Living Environments (GLEs) receive varying levels of care from our nurses—ranging from weekly check-ins to daily care in our more medically-intensive homes for people with severe needs. In those programs, nurses support patients dealing with the after-effects of strokes and other acquired brain injuries (ABI), various forms of cancer, arthritis, heart conditions and other chronic illnesses.
When George came to our Hyde Park Avenue (HPA) residential program for individuals with intellectual disabilities, his physical condition was poor. Weighing in at 311 pounds, George suffered from diabetes, congestive heart failure, and asthma—physical ailments that were complicated by his depression, bipolar disorder and intellectual disability. He had a history of DVT embolisms and, in the words of Nurse Manager Mona Ojugbana, “George couldn’t walk more than a couple of steps without being out of breath.”
“I was like THIS!” George says, holding his arms as far apart as he can. “Not good.”
Upon his arrival at Bay Cove in 2017, Mona and the other nurses at HPA made it a priority to get George engaged with improving his health and, above all, losing weight. “We knew we had to work to educate George about how to take better care of his health, and make better decisions,” Mona says.
So, the nursing staff designed a plan for George that included caloric and fluid restrictions, smaller portions, healthier choices, and ramping up his physical activity—all of which Mona says George took to well (if not with a bit of grumbling at times). “George has done everything that was asked of him. He isn’t afraid to speak his mind if he disagrees with something, but his cooperation with the nurses and staff speaks volumes to his strength and character.”
It’s been a long process, but five years later, the results are astonishing. George now weighs 220 pounds—a 90 pound weight loss. Mona notes that he’s been able to get off all his medications for diabetes—including insulin. He rarely has to use the rescue inhaler that was a constant presence in the past. And, as far as mobility goes, “He walks everywhere now—thousands of steps a day—sometimes he doesn’t even use his walker!” Mona laughs. “I have trouble keeping up with him sometimes. I love to brag about him—he should be very proud of himself.”
Diabetes is just one commonly seen chronic condition for people we serve throughout the agency, and it’s one that’s particularly difficult to help someone with a mental illness manage. “We have people we work with who have a bipolar depression diagnosis, and during their manic stages they can tend to rely a lot on food as a coping mechanism,” says Henrietta Imade Wood, a Nurse Consultant with the Adult Community Clinical Services (ACCS) program in our Mental Health Services division. “Food may be helping their mental state, but at the same time you want to ensure that they’re not overeating and elevating their blood sugar. Or, on the flipside, they may not be eating at all because of their depression, and then you have to worry about hypoglycemia (low blood sugar).”
Nurses rely on their close collaboration with Bay Cove’s non-medical program staff and behavioral clinicians—who are more likely to see those we serve on a daily basis—to ensure that a care plan is designed and executed that will keep people healthy. “It’s very much a team approach,” Henrietta says. “We work to ensure that program staff are equipped with the knowledge—that they know each person’s diagnosis, the signs to be on the watch for. There’s a lot of communication that goes back and forth between us, the direct care staff, and the individuals. The clinicians give us support through their behavioral plan, while we’re there to manage medical needs.”
Bay Cove’s nursing team also plays a critical role—in collaboration with medical providers outside our agency—in tracking the wide array of medications (prescribed and otherwise) used by some in our care, and working to ensure that patients avoid complications from drug interactions. As a leader within ACCS’s MAP (Medication Administration Program) team, Henrietta makes sure that staff and clients respect and adhere to a strict protocol involving medications.
“MAP is very insistent that our individuals get a physical every year,” she says. “Additionally, we don’t use a psychiatric order for any longer than three months—at that time, they have to go and see their psychiatrist. Our whole MAP auditing process is stringent, but it’s because we’re trying to prevent negative outcomes and fatalities. It’s really important that we all follow the rules to keep each person we serve as healthy and safe as possible.”
“The work done by our nursing staff goes so far beyond the superb medical treatment they provide,” Dr. Diener says. “They’re helping people schedule and attend medical appointments, and understand the information about their conditions that they receive there. They’re helping people with cognitive and psychiatric challenges negotiate the healthcare system, which can be a challenge for anyone, never mind someone with a disability. They’re assessing whether clients who are being discharged from hospitals are healthy enough to return to their Bay Cove residences, and advocating for them if there’s any question at all that they are. There’s no doubt that our nurses have an incredibly positive impact on the lives of the people we serve.”
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