Home Health Care: Care That Is Right for the Times
One hundred twenty-five years ago, the New York City tenement communities of Manhattan’s Lower East Side — the first American homes for waves of new immigrants — were characterized by close, squalid quarters where illness often went untended and disease spread rapidly. There was no appropriate model of care for this population, so a young nurse named Lillian Wald created one. Together with a team of compassionate, committed nurses, Wald took health care directly into these tenement homes, climbing countless flights of stairs to tend to the poor and forgotten.
These dedicated care providers examined vulnerable newborns and taught their mothers how to sterilize milk, they dressed wounds, connected critically ill residents with physicians’ care, and battled epidemics of polio and the Spanish flu, collecting data and helping to coordinate the citywide response.
Wald’s in-home care, patient education and social advocacy was uniquely responsive to the needs of turn-of-the-century and early twentieth-century New York. Since then, the agency she founded — the Visiting Nurse Service of New York — has remained at the forefront of delivering care that is right for the times, meeting the at-risk and vulnerable where they live and bringing them the care they need most.
Today, as America’s 65+ population continues to expand dramatically with the aging of the Baby Boomers, a growing number of people are living with one or more chronic illnesses. At the same time, seniors are increasingly expressing a desire to remain in their homes as they age, surrounded by the familiar and connected to their communities. As we always have throughout our long history, VNSNY is taking the lead in this regard.
Over the past several years, for example, we’ve continued to refine evidence-based tools for helping people manage their medical conditions in a home setting, from telehealth equipment that lets us remotely monitor the vital signs of home care patients, to training programs that teach home health aides to spot and immediately alert us if a client’s condition seems to be worsening, to collaborations with local medical centers that bring emergency medical services directly into patients’ homes.
Insurance-Based Care Management for Vulnerable New Yorkers
We’ve also taken the lead in designing insurance plans that support Baby Boomers’ desire to age in place. Twenty years ago, VNSNY CHOICE Health Plans established one of New York State’s first Medicaid managed long term care (MLTC) plans. These plans are designed specifically to provide care for vulnerable New Yorkers who tended to “fall through the cracks.” Two decades later, CHOICE MLTC is doing exactly that, by helping vulnerable New Yorkers with multiple chronic conditions manage their health care safely and comfortably at home.
Through VNSNY CHOICE, we coordinate all aspects of care for our members, including even the frailest elderly. Our care management teams help plan members get to doctors’ appointments, manage medications, navigate health as conditions change, and learn about their illness so they are better able to manage their physical and behavioral health over the long term.
In fact, the health care industry as a whole has caught up with what public health nurses, starting with Wald and continuing with today’s visiting clinicians, have long known and practiced: The true value of health care lies in attending to whole-patient wellness. Health care today is rapidly shifting from the old model of volume-based fee-for-service delivery of care, in which practitioners are paid for each visit or procedure, to value-based payment models that take patients’ outcomes in consideration, and that aim to keep people as healthy as possible while keeping down costs (including minimizing avoidable hospital visits).
This approach is directly in line with our public-health mission at VNSNY to keep patients and communities as healthy as possible. Once again, VNSNY is helping to lead the way in this evolving area, and a growing proportion of the care we provide now involves value-based models.
A 125-Year Legacy: Evolving to Meet People’s Needs in Changing Times
By its very nature, home health care is highly responsive to the conditions and crises that burden and benefit daily life. As VNSNY celebrates its 125th anniversary and Wald’s powerful legacy, we are inspired by the committed clinicians who rise to meet the needs of at-risk populations in changing times. Here is a look at a few of the more recent chapters (for a full timeline of public health nursing, click here).
The AIDS Crisis
Nearly a century after Wald invented the field of public health nursing, New York City once again found itself without a working care model for an alarming new illness that was spreading through communities of gay men, people of Haitian descent, and those with hemophilia or who used intravenous drugs. This was, of course, the AIDS crisis of the 1980s, and VNSNY nurses were right there on the front lines, caring for many of the earliest cases. The organization provided comprehensive education about the disease to its clinicians, who then played a lead role in caring for those swept up in the epidemic. “We’ve always cared for patients, whatever condition they might have,” says Marilyn Liota, who retired in 2012 after 60 years as a VNSNY nurse and regional vice president. “In the AIDS epidemic, once we knew what we were dealing with, we used what we’d always used before — universal precautions. A patient is a patient. An illness is an illness.”
Early on, caring for AIDS patients involved largely palliative measures, as most victims died shortly after diagnosis. Later, VNSNY helped pioneer approaches to treat, track and care for the growing number of women who were contracting HIV/AIDS and transmitting it to their babies during childbirth, including direct care, respite service for overburdened parents, and charitable care to support the myriad needs of patients and their families.
9/11
On September 11, 2001, New York City experienced loss, devastation and fear on a scale the city had never seen before.
VNSNY nurses rushed to triage centers and local hospitals, while our social workers and mental health counselors assessed people’s needs and offered their services. At the time of the attacks, VNSNY had 1,600 patients living in Lower Manhattan, most of them frail elderly or chronically ill. Our clinicians rose to the occasion, overcoming transportation and communication barriers to reach and treat their patients. Not knowing what they’d find, VNSNY workers carried surgical masks, medicines, food, water, flashlights and radios to their patients. Home health aides extended their shifts and remained at patients’ bedsides, sometimes overnight, until a replacement arrived. And clinicians worked tirelessly after the event to meet mental health needs of patients who saw from their windows the collapse of the World Trade Center and the chaos and devastation that followed.
Superstorm Sandy
When New York was hit by devastating Superstorm Sandy in 2012, it disproportionately affected the vulnerable, the sick, the elderly and the homebound. During Sandy, VNSNY workers provided a lifeline for thousands of homebound New Yorkers as well as those newly cut off by the storm.
With no public transportation operating, our staff drove or took cabs through abandoned streets, rode bicycles or Vespas, roller skated or walked — often miles, and sometimes in knee-high water — to see their patients. In those buildings that had lost power, the clinicians climbed darkened stairwells and even worked with flashlights strapped to their heads while they changed bandages. We continued to learn from the lessons of Sandy, and our upgraded emergency planning resulted in safe, uninterrupted care delivery during subsequent extreme weather events such as the near-record snowfall in 2016.
“VNSNY is a lot like the Fire Department of New York — running towards where they are needed, not away from it,” says Joseph Gallagher PT, DPT, Director of Clinical Operations Support. “When other people are staying home to wait out the storm, our clinicians are heading out into it to make sure their patients get the care they need. Home care takes a special person.”
Data Supporting a New Health Frontier
Research and what we now call “evidence-based” practices have been critical to the VNSNY mission from the very beginning. We’ve launched numerous groundbreaking research projects and our Center for Home Care Policy & Research is supported by the New York State Department of Health and some of the most prestigious granting organizations in the country. As Kathryn H. Bowles, vice president and director of the Center said in a recent article in Home Health Care News, “Many of the contracts that we’ve had over the years have been from payers asking us to help them figure out what works and what doesn’t work. Quality is so important from a business standpoint. Your customers look to you, and they want to know you are a cutting-edge agency using the best evidence to provide high-quality care.”
Working in New York City, the nation’s largest and most diverse urban environment, we provide care for a particularly robust spectrum of people across a wide variety of cultural and medical determinants. From hypertension and heart failure studies to falls prevention, hospital discharge prioritizations, sepsis studies and myriad decision tools and population-driven interventions, the data and analysis that we are able to gather shows that the some of the most effective care and prevention strategies take place in the home — outside the hospital or doctor’s office setting.
LGBT Care for Older Adults
It is estimated that there are more than three million lesbian, gay, bisexual and transgender Americans aged 55 or older, and these individuals often find themselves without equal access to health care, and, according to SAGE (Services and Advocacy for Gay, Lesbian, Bisexual & Transgender Elders), they face greater health risks as they get older.
In home health care, we take care of isolated, vulnerable patients all the time, and we are highly competent at assessing what they need to stay safe and independent in their homes, on their own terms. Because we see people in the full context of their lives — in their homes, as opposed to clinics or doctors’ offices — and can assess and meet their needs in ways that go beyond the physical, we are the perfect workforce to bridge this gap in care and ensure that LGBT older adults have access to the physical, emotional and social supports they need and deserve. VNSNY proudly holds Platinum certification in LGBT cultural sensitivity from SAGE across our entire organization.
Throughout these changing times — whether in the midst of a city- or nationwide crisis or simply carrying out the day-to-day home visits to provide care and peace of mind — our visiting clinicians remain true to the mission of public service that Lillian Wald began more than a century ago. Our recent company-wide celebration of VNSNY’s official 125th anniversary was an opportunity to reflect on our organization’s rich history, but for us, this milestone has also been very much about looking to the future. In our next 125 years, VNSNY will continue to respond to public health crises, and to pioneer new models of care delivery where vulnerable people need it most — in their homes and communities.
