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Nursing Home Without Walls

Vol. 5 •Issue 25 • Page 14
Nursing Home Without Walls

Home health program helps keep New York City's Medicaid-eligible patients out of nursing homes and hospitals

For many elderly residents in New York City, the ability to live safely in their own homes is a daily balancing act that easily can be thrown off kilter by an unexpected illness or injury.

In the past 25 years, the Long Term Home Health Care Program (LTHHCP) of the Visiting Nurse Service of New York (VNSNY) has served as a safety net, providing comprehensive home health services that have kept thousands of Medicaid-eligible patients in Brooklyn, Manhattan, Queens and the Bronx out of nursing homes and hospitals.

Commonly known as the "Nursing Home Without Walls" program, LTHHCP is the largest program of its kind in the United States and serves a model for other states. Established by a healthcare bill championed by state Sen. Tarky Lombardi, LTHHCPs provide the same services that an individual would receive in a nursing home, with costs capped at 75 percent of the nursing home rate.

At VNSNY, RNs serve as coordinators of care (COCs) to manage all of the care the client needs in the home, providing consistent assessment that helps identify needs before they turn into problems.

Coordinators of Care

Florence Marc-Charles, RN, NPA, CHCE, program director, has been with the program since 1982, when it served only 75 patients in Queens. Today, she oversees the care of 2,500 patients in Manhattan, the Bronx, Brooklyn and Queens.

"We have the most comprehensive home care program that provides an alternative to nursing home placement for patients who require long-term care," Marc-Charles remarked. LTHHCP delivers professional services from nurses, social workers, clergy and nutritionists, along with support services such as home health aides (HHAs), personal care workers, housekeepers and homemakers.

Peggy Bogdonoff, RN, acting clinical director of the program in Queens, described the oversight role of the COCs. "When a patient needs professional or support services, the COCs are responsible for getting the physician orders. They data-enter everything into the computer at the client's home, and the orders then print out at the office so they're ready to sign and mail to the physician when the nurse comes in," she said.

Patricia Horton, BSN, RN, spoke passionately about her role as a COC in the Bronx office.

"We've been very successful in keeping our patients at home and reducing unnecessary hospital and nursing home stays because we follow our patients for the long term; they know us and we know them well," Horton said.

"We're able to recognize those subtle early warning signs that tell us something is about to happen with that patient. We can refer the patient to the doctor immediately and avoid what might be a 911 call otherwise."

RN Accountability

Each COC is responsible for a particular caseload of patients and accountable for coordinating the home care services.

"Seventy-five percent of the cases on my team will be chronic and stable patients, with some exacerbations periodically," Bogdonoff said. "It's always a balancing act for the nurses to juggle the acute exacerbations within caseloads."

The COCs provide skilled nursing assessment and direct patient care on their regular visits. They also teach HHAs to perform certain tasks.

"The HHAs are helpful in keeping logs of blood glucose levels, pulses and any other changes that may occur between our regular visits," Horton said. "This comprehensive model of care has made a huge difference in the lives of virtually every patient we see."

Originally designed to provide a cost-effective alternative to nursing home care, LTHHCPs must demonstrate fiscal accountability. Lisa Heller, RN, a patient services manager in Queens, pointed out that the COCs are expert at coordinating care within the 75 percent cap.

"The nurses who manage the care for our patients have to control the use of the available resources and are well aware of the dollars spent," Heller said. "They actually have to write it out every 120 days: how frequently they go to see the patient, the cost of transportation and supplies, how many home health aide hours are provided and how much those hours cost.

"They have hands-on knowledge of what these services cost."

All in a Day's Work

Zelma Perez-Sandy, BS, RN, LM, CCRN, a COC in Queens, described a typical shift.

"My day starts at home, where I communicate on my computer to get any updates or anything new about my patients," she said. "Then I call the patients who I'll be seeing that day to let them know when I'll be there."

Teaching is a large part of Perez-Sandy's role as she works diligently to provide the comprehensive care that will allow her patients to safely remain in their own homes and have the best possible quality of life.

"When I walk into the home of an elderly woman with diabetes, the first thing I ask is how she slept that night and how she is feeling," Perez-Sandy said. "Then I want to know what she remembers about her condition, what she recalls of the teaching that was done about her diabetic care and how her blood sugars have been running."

Because many of her elderly patients are confused or forgetful, Perez-Sandy monitors their health closely and tries to make their disease management as easy as possible.

"At each visit, I'll reinforce my previous teaching and check the patient head to toe. I pre-pour their medications and place them in a box for Saturday through Sunday, morning through night. At my next visit, I can see if they've forgotten to take any of their doses."


Deborah Wright, MPA, RN, a patient services manager who makes periodic visits to the homes of patients in the Bronx, frequently is amazed at the changes she sees over time.

"It's remarkable to see how some of them come into the program so disheveled, depressed and barely talking," Wright said. "A year later, they're socializing and seem like different people. The interdisciplinary care we provide and the support from everyone on the team make a tremendous difference in their lives."

Angela Williams, LMSW, social work manager in Brooklyn, described the contribution that her staff make to the patient's well-being. "Social workers provide supportive counseling to help the LTHHCP patients deal with their impaired function and changes in their lives. We use different frameworks for this counseling, which might include behavioral therapy or cognitive therapy over a relatively short period of time."

Angelina Abad, MA, RD, CDN, nutrition manager for the LTHHCP, heads a team of nutritionists who work closely with the COCs to deliver cost-effective care that maximizes the health status of the patients.

"One of my roles here is to help patients improve their intake, which will in turn decrease hospitalizations, lower healthcare costs and minimize the costly complications of diabetes, congestive heart failure and other diseases seen in our elderly population," she said.

"Since our patients are Medicaid-eligible, we see many low-income patients from various cultures who may have different levels of reading skills," she added. "We have to tailor our nutritional counseling to fit their particular needs."

Abad has hired nutritionists from various cultures who speak the patients' languages and have access to educational materials in 20-25 languages, including Somali, Vietnamese, Cantonese, Mandarin, Spanish, Greek and Farsi.

Improving Nursing Practice

Wright talked about VNSNY's learning collaboratives that focus on key issues in nursing practice. "One area of concern is diabetic teaching and the overall health of our patients with diabetes. Working with a diabetes specialist, we recently took our teaching materials and spread them out over a period of time.

"We'll share 2-3 pages of the teaching plan with the patient at each visit, then review at following visits to see how much the patient retained," she said. "The HHAs became involved, and some of our patients who weren't learning actually began to listen."

Wright's team now holds weekly rounds on patients with diabetes and has completed another learning collaborative to improve the communication between HHAs and COCs to reinforce the diabetic teaching.

VNSNY is deeply committed to evidence-based practice and continuing improvement. "We've been doing a research study with Pace University about evidence-based practice," Bogdonoff said. "And we're starting to implement what we've found right now in order to improve our outcomes and increase patient satisfaction."

While research is important, it's the response from patients that truly measures the success of the program, Horton said.

"I really feel in my heart that, if we didn't have this program, medical costs would be higher because our patients would be in nursing homes or hospitals when they would rather be home with their families," she said.

"My patients don't have much to share, but there's always a glass of ice water waiting for me, along with a smile and warm greeting. That appreciation for what we do fills my heart."

Sandy Keefe is a regular contributor to ADVANCE.

Keeping Patients Off the Streets

"Let me tell you a story," urged Lisa Heller, RN, patient service manager in the Long Term Home Health Care Program (LTHHCP) for the Visiting Nurse Service of New York.

"We received a referral for a patient who had some history of mental illness, severe hypertension and uncontrolled diabetes, and no family members were around. She wasn't homeless but was always on the edge and spent her days wandering the streets collecting bottles," Heller continued.

"She kept ending up in the ED, so she was referred to us [the LTHHCP] and the nurse worked very hard with her to get her medication-adherent."

Scheduling early morning visits to catch the woman at home before she hit the streets, the coordinator of care (COC) made sure the woman was taking her medications, checked her blood glucose and would see if there was anything else she could do for the patient.

"One day the nurse ran into her at McDonald's and hardly recognized the woman. She had a very swollen face from an allergic reaction to one of her medications," Heller said.

The nurse called 911 and the woman went to the hospital.

It was during that hospital stay that a niece who had had minimal contact with the woman showed up.

Care Plan Established

Heller met with the niece and the COC to develop a plan to improve the woman's quality of life and keep her out of the nursing home. "We decided to see if a day program would help her and made arrangements for her to go to one that provided socialization along with two meals a day."

Since the woman had poor hygiene habits, the COC also set up some home health aide hours.

"What a turnaround! It's been 2 months now, and the woman is up and ready for the transportation van each morning," Heller said. "She's out in the community now as part of the day care program, going to Wal-Mart and the movies and socializing with the other clients."

For the first time in this woman's life, she is taking her medications regularly. Her hypertension and diabetes are under control.

"Her life was on the streets, but now she's enjoying a new life within the community," Heller said. "If we hadn't intervened, realistically, she probably would have died on the streets.

"And all of this — the day care program, the transportation, the nursing visits, social work services and home health aide hours — are provided within the 75 percent cap that we face under this program."

– Sandy Keefe

Managing the Dollars

"When I was younger I worked in retail, but I was young and idealistic and changed to nursing because I wanted to help people without dealing with money," laughed Lisa Heller, RN, patient services manager for the Long Term Home Health Care Program (LTHHCP) at the Visiting Nurse Service of New York.

Today, Heller supervises a team of dedicated nurses in Queens who coordinate the delivery of high-quality home healthcare services within a budgetary cap established by the state.

When orienting new nurses to the LTHHCP, Heller talks about the history of the program and emphasizes the importance of ensuring its continuance.

"Many of our nurses have been here a long time and have gone more than once to Albany to fight for this program when it was threatened by budget cuts," she told ADVANCE. "I tell new nurses that if we'd like to continue to provide this level of care, we have to be very frugal in our provision of services. We have to give the patients what they need, but only what they need."

Global Thinking Required

Heller is cognizant of the nursing responsibilities within this Medicaid-funded program. "New York state provides funding to the Lombardi program, and it's our job to use these resources wisely and really think globally about what we provide.

"We can't put a home health aide into the home just because the patient doesn't like to be alone, but we can provide home health aide hours to pick up where the family leaves off when the daughter has to go to work, or for a patient who can't safely be alone in the home," she said.

Beginning in her teens, Heller worked first at a supermarket and then at a home improvement store, moving up through the ranks. When she decided to change to a more human approach to life instead of focusing on the buying and selling of goods, she had no idea that her business background would be so helpful.

"The basic information about finances, cost of services and the importance of managing time and managing hours has been invaluable in my nursing career," she said.

"We're very fortunate in New York state to have the resources that we have; there are a lot of states that don't have this type of long-term care program," she added. "I don't ever want to take it for granted."

— Sandy Keefe


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