Improving Medication Management Practices and Care Transitions through Technology (IMPACT)

The goal of this randomized-controlled study is to design and test a medication management strategy that harnesses the power of information technology (IT) to facilitate high quality care transitions through improved clinician practice and enhanced patient engagement. 

Self-management of urine flow in long-term urinary catheter users

Many individuals with long-term indwelling urinary catheters experience persistent catheter-related problems, such as blockage or urinary tract infection. Data from the investigator’s preliminary studies indicate that urinary catheter self-management could be beneficial in preventing or minimizing catheter-related problems.

Promoting Readiness and Interest in Self-Management (PRISM)

The purpose of the project is to promote patient-centered care by identifying and providing recommendations to overcome barriers and to cultivate facilitators of clinician involvement in promoting patient self-management.

Collaboration for Homecare Advances in Management and Practice (CHAMP)

The purpose of this initiative is to improve home healthcare by embedding in home care agencies the capacity for continuous practice improvement. The specific aim is to develop and test a sustainable training model for nurse managers in home healthcare agencies. In turn, the nurses they manage will be equipped to employ "best geriatric practices" in the care of their older patients.

Home-Based Blood Pressure Interventions for African Americans

The goal of the study is to conduct a randomized trial to examine the effectiveness and cost-effectiveness of two organizational interventions aimed at improving blood pressure control among a high-risk, African American home care population.

Beatrice Renfield Evidence-Based Practice Improvement Fellow Program

The primary purpose of the Renfield EBPI Fellows Program is to prepare clinical managers with the knowledge, skills and opportunities to evaluate and apply relevant evidence to improve practice that addresses VNSNY quality initiatives and strategic priorities. The clinical manager is ina pivotal position to create and support a professional climate that integrates evidence-based practice improvement into daily practice in a way that is relevant and sustainable.

Establishing a National Framework for Geriatric Home Care Practice

This project will develop a broad set of national priorities that define the key areas to be addressed in geriatric home care. The goal is to initiate the development of practice guidelines that promote the provision of effective, patient-centered care at home for older adults. The project responds to both providers who need to base quality improvement efforts on gold standards for geriatric home care and to patients and informal caregivers who need to be able to identify good care and make informed choices.

First 30 Days: An Exploratory Study

Patients and families are often faced with managing increasingly complex health needs after being discharged home from the hospital.  Patients are at risk for re-hospitalization or other complications during the transition home after being hospitalized. Understanding the events from the perspectives of the patient, informal caregiver and healthcare professionals will add to our understanding of the risk factors contributing to re-hospitalization and/or barriers hindering patients abilities to mange their care and achieve independence. 

AIM: Testing an Advanced Illness Management Model

Over two years, VNSNY will implement, evaluate, estimate the return on investment, and develop a business case for an Advanced Illness Management (AIM) model that can be broadly replicated by Medicare/Medicaid certified home health agencies (CHHAs) in New York State and the U.S. The goals of AIM are to improve the quality of care, increase use of hospice services and reduce hospitalization by improving advanced illness management for severely ill homecare patients. The model will be tested in a cross section of VNSNY's service areas.

RAND-Hartford New York City Interdisciplinary Geriatric Research Center

The purpose of the New York City Interdisciplinary Geriatric Research Center (NYC-IGRC) is to establish a self-sustaining research and education center that promotes Community-Based Participatory Research (CBPR) as a means of translating basic research into practice to improve the health and healthcare of older adults in NYC.

Telemedicine Integration Project

This project conducted a scan of VNSNY’s internal and external environments to The Visiting Nurse Service of New York’s (VNSNY) proposed demonstration seeks to enhance the adoption of Telemedicine as an adjunct and resource to home health care delivery by physicians, nurses and patients by making these data more accessible and easier to use.

NYS Partnership

The purpose of this project is to provide the New York State Partnership for Long- Term Care with the following estimates: a) a profile of the group of New Yorkers who can afford Partnership insurance but would fail medical underwriting; b) their rate of LTC use; and c) the underwriting criteria which currently prohibits insurers from issuing coverage but, had coverage been issued, would have resulted in LTC use similar to that of the underwritten population.

Pforzheimer Planning for "Patients First"

This project conducted a scan of VNSNY’s internal and external environments to better understand chronic care issues among home care patients and to identify promising opportunities for enhancing patient-centered care at VNSNY and in the wider home care sector.

Assessing Home Health Care Quality for Post-Acute and Chronically Ill Patients

Home health agencies serve Medicare beneficiaries with relatively short-term post-acute care needs as well as individuals who are chronically ill and have more long-term needs. Publicly reported outcomes for home health agencies, however, are the same for all patients. Whether the current approach to assessing the quality of home health care adequately captures potential differences in care provided to distinct groups of Medicare beneficiaries is unknown.

The Effect of the Patient Activation Measure in Chronic Care

The purpose of this project is to test the effectiveness of an intervention -- in a chronically ill managed long term care population -- that provides nurse Care Managers and their interdisciplinary teams with an Intervention Package of hypertension management strategies. This package contains a range of interventions that can be individualized and geared to each person's Patient Activation Measure (PAM) score. The Care Teams randomized into the intervention group will use the Intervention Package in conjunction with a patient's PAM score to design an individualized management plan for patients. The intervention will be assessed relative to usual care (comparison group). The analysis will estimate the impact of the intervention on blood pressure outcomes and change in PAM raw scores. Secondary analysis will examine patient knowledge and self-management skills. In addition to the quantitative analysis, a qualitative analysis will be conducted on the implementation of the intervention, and the perceived usefulness of a short PAM Visual Scan Assessment tool for Care Managers.

Promoting Healing Through Falls Prevention Among Older Adults: Linking Family And Formal Home Health Caregivers

This two-year project will pilot test and evaluate the impact of an intervention that aims to improve patient outcomes by developing a more family-centered approach to care management. The project focuses on older adults at risk of falls admitted to home care for physical therapy services at VNSNY. This multifaceted intervention is designed to increase family caregiver participation in the rehabilitation process and prevention of falls by standardizing how they are engaged by PTs and by improving caregiver knowledge, skills and confidence.

Enhancing Palliative and Home Hospice Care Services to Minority Patients

The goals of this study are to examine barriers to home hospice referrals in minority populations and to create and test an intervention for minority patients that will enhance the quality of palliative care, increase hospice referrals, and increase length of involvement in the hospice program.

Development of E-Transitions Tools for Home Health Care

The purpose of this project is to evaluate the impact of a redesigned and automated CMS Home Health Certification and Plan of Care form. This redesigned form is intended to promote physician involvement in discharge planning, increase the quantity and accuracy of patient data during patient transitions, and promote evidence-based practices. The project also will further develop and pilot test e-transitions, a web-based hospital-home care transitions intervention intended to improve care and outcomes for heart failure and other patients.

Home Health Partnership Evaluation

The purpose of this project is to evaluate the impact of the Home Health Aide (HHA) Partnering Collaborative on patient outcomes, and on positive changes in employee and organizational culture. The specific aim of the Collaborative is to optimize the role of the HHA as part of a care team, resulting in patient services matching need, better patient self-care, continuity of care, and improved satisfaction among HHAs, patients, and staff.

Providing Palliative Care Consultation to Older Adults in Home Care

The objective of this study is to improve patient pain and symptom management, advanced care planning, emotional adjustment, and quality of life by building an effective intervention partnership model between Coordinators of Care at VNS Hospice and VNS acute care.

Alternative Risk Adjustment Approaches to Assessing the Quality of Home Health Care

To develop and test alternative risk adjustment approaches to assessing the quality of home health care.

Improving Transitions and Outcomes for Heart Failure Patients Through a Hospital-Home Care Information Exchange

To design and pilot test an information-based hospital-home care transition intervention intended to improve care and outcomes for heart failure patients.

Assessing Family Satisfaction with Children's and Family Services at the Visiting Nurse Service of New York

To assess quality of care and improve service delivery, this study evaluated family satisfaction with services provided by VNSNYís Division of Childrenís and Family Services.

Partnership for Advancing Quality Homecare (PAQH)

To create a mechanism and model for home care organizations to collaborate in order to identify aims for improvement.

Factors Associated with Increased Job Satisfaction and Quality Care Provision and Coordination

To examine the factors associated with increased jobsatisfaction among home health employees and elements of the job that theyperceive to be critical to providing and coordinating high-quality care.

Research, Education, and Assessing Care for Homecare Safety (REACHomeS)

To advance the understanding of and teaching about medical errors in home health care and to develop ways to learn from such errors and thereby reduce them.

Working Conditions & Adverse Events in Home Health Care

To gain an understanding of the relationships that exist among characteristics of the home care work environment, the home care workforce, and patient care errors and preventable adverse events in the home care setting.

Toward Improving Parental and Infant Outcomes: An Evaluation of VNSNY'S Early Head Start Program

To evaluate the degree to which VNSNY's Early Head Start program improves parental and infant/toddler health and social outcomes.

Effort for Quality Improvement and Performance in Home Health Care (EQUIP)

To promote quality improvement in home health care by assessing and improving the current knowledge base.

Black Elders in Home Care: Contributors to Successful Recovery

To explore whether and to what extent recovery differs between minority and non-minority elders receiving home care.

Children with Asthma in Home Care: An Evaluation of Population Characteristics and Needs

To examine the characteristics of children with asthma who received home care through the Visiting Nurse Service of New York (VNSNY); what triggered their asthma; if their illness was managed according to national guidelines; what kind of health care services they used; the level of knowledge that their family caregivers have about asthma; and whether there were any disparities between children who received care through VNSNY's charitable care program and those who did not.

The Road to Recovery: The Effects of Informal and Formal Home Health Care Services on Older Adults

To determine how informal and formal care affect the physical and psychological recovery of adult home care recipients with several common home health admission conditions, whether there is a relationship between the use of informal and formal care, and how the various components of informal and formal care interact with each other.

Evidence-Based Reminders in Home Health Care (a.k.a. TRIP)

To test the effectiveness and cost-effectiveness of two email-based interventions targeted to home care nurses, designed to promote their adoption of clinically proven practices and to improve patient outcomes.

Review of Assessment Instruments for Individuals Receiving Home-Based Long-Term Care Transitions Among Post-Acute and Long-Term Care Settings

To identify the frequency and patterns of transitions to or from post-acute and long-term care settings (rehabilitation facilities, nursing homes, care settings such as psychiatric facilities, and formal home health care), for a nationally representative group of seniors. The study also aimed to identify events that might indicate problems with transitions and the frequency with which these events occurred.

Transitions Among Post-Acute & Long-Term Care Settings

To identify the frequency and patterns of transitions to or from post-acute and long-term care settings, for a nationally representative group of seniors. Also to identify events that might indicate problems with transitions and the frequency with which these events occurred.

The National Informal Caregiver Survey Research Study

To help create a sound basis for recommending changes in public policy and health care practice to ease the burdens on family caregivers by identifying the experiences and unmet needs of these caregivers.

Preferences for Everyday Living Inventory (PELI): Developing an Instrument to Inventory Lifestyle Choices

To pilot-test a questionnaire that would capture elders' preferences for everyday living. Such an inventory of preferences could be used to tailor services to individuals receiving long-term care and could serve as an "advance directive" should seniors become cognitively impaired.

Implementation and Evaluation of an Evidence-Based Nursing Intervention to Improve Medication Management of Diabetic Patients in Home Care

To determine if an evidence-based quality improvement strategy would help elderly, homebound persons with diabetes in home care achieve better control of blood glucose levels; increase confidence in their ability to take medications as prescribed and manage their diabetes; and reduce their emergency department use.

Information Strategies to Support Consumer- and Family-Centered Care in Managed Long-Term Care Settings

To identify strategies to help managed long-term care programs elicit consumer and family preferences, incorporate those preferences into care, and measure the results.

Improving Pharmacotherapy in Home Health Patients

To test the effectiveness of an inexpensive program to improve medication regimens for elderly patients receiving home care from two large home care agencies.

Developing a Survey of Consumer-Centered Community Care

To develop a valid survey instrument to measure quality in home care and community-based settings from consumers' perspectives, which can be used by health care managers in a wide range of geographical areas.

Assessing the Use of Televideo Technology to Enhance Medication Compliance Among Elders with Congestive Heart Failure

To determine whether daily videophone or regular telephone reminders would increase medication compliance among frail elderly individuals with congestive heart failure living at home.

Implementation and Evaluation of Health Outcomes Management and Evaluation (HOME© Plans) for Home Health Patients with Congestive Heart Failure

To test the effects of the Health Outcomes Management and Evaluation (HOME©) Plan, a quality improvement tool developed by the Visiting Nurse Service of New York (VNSNY), to determine its benefits for home care patients with congestive heart failure.