Improving Medication Management Practices and Care Transitions through Technology (IMPACT) – Focus on the Cognitively Impaired

This study extends the medication optimization intervention developed through the AHRQ-funded IMPACT initiative to the cognitively impaired patient population and their caregivers. 

Capturing the Quality of community Care Transitions with the CTM-3 (Care Transitions Study)

This study aims to build the evidence base to support the dissemination of the 3-item Care Transitions Measure (CTM-3, developed by Eric Coleman and colleagues) to improve transitional care in the post-acute home health setting.  

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

The 4-year study uses a two-arm randomized clinical trial design to test the effectiveness of a urinary catheter self-management intervention developed by the PI based on previous work. 

Promoting Readiness and Interest in Self-Management (PRISM)

The purpose of the project was 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. 

Establishing a National Framework for Geriatric Home Care Practice

The goal of the project was to influence the future of geriatric home care by making the framework available to accrediting agencies, public and private purchasers and home care organizations to guide and assess the delivery of home health services to older persons.

The Geriatric CHAMP Program as an Expansion of a Framework for Geriatric Home Care Excellence

Specifically, the expanded Geriatric CHAMP Program will achieve three broad aims: 1) Build geriatric capacity in a significant number of home care agencies nationally; 2) Establish an active, ongoing Community of Practice to motivate and support quality improvement in geriatric home care; and 3) Achieve significant, measurable improvement in home care for older persons.

Beatrice Renfield Nursing Research Program

The aim of the Renfield Nursing Research Program is to support work the development and dissemination of new models of home health nursing practice and education that can significantly enhance patient care, increase professional satisfaction and influence the nursing arena both internally and nationwide. 

First 30 Days: An Exploratory Study

The primary objective of this study was to describe the home care experiences of home care patients, their informal caregivers, and formal caregivers during the first 30 days following a patient's discharge home from the hospital. 

AIM: Testing an Advanced Illness Management Model

The goals of AIM were to improve the quality of care, increase use of hospice services and reduce hospitalization by improving advanced illness management for severely ill homecare patients.

Telemedicine Integration Project

This demonstration enhanced the adoption of Telemedicine as an adjunct and resource to home health care delivery by physicians, nurses and patients by making clinical data more accessible and easier to use. 

Interdisciplinary Geriatric Research Center in NYC (IGRC) (Rand Hartford)

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.

Health Related Quality of Life: Elders in Long Term Care (HRQoL)

The purpose of this project is to examine at the HRQoL of chronically ill elders who have recently started to receive long term care (LTC) services.

Pforzheimer Planning Grant: "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.

Effect of the Patient Activation Measure on Chronic Care (PAM)

The purpose of this project was to test the effectiveness of an intervention -- in a chronically ill managed long term care population -- that provided nurse Care Managers and their interdisciplinary teams with a change package of evidence-based hypertension management strategies.

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

The key objective of the project was to demonstrate that involving family caregivers in the recovery process of older homebound adults at risk for falls will enhance such patients’ healing trajectory, resulting in improved physical functioning, shortened recovery periods, and a reduction in the incidence of adverse events including recurrent falls, unanticipated hospitalization, and emergent care use.

Enhancing Palliative and Home Hospice Care Services to Minority Patients

The goals of this study were 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.

A Home Health Setting Collaborative Change Package to Enhance Quality of Care for Patients with Chronic Conditions and Avoid Unnecessary Hospitalization Admissions

The primary objective of this project was to develop and test a comprehensive Change Package that can be used by Quality Improvement Organizations as they help their Home Health Agencies (HHAs)  implement improvement initiatives to improve patient outcomes and to reduce avoidable hospitalization for their patients with chronic conditions.

Home Health Aide Partnering Collaborative: Evaluation

The purpose of this project was to evaluate the impact of the Home Health Aide (HHA) Partnering Collaborative on patient outcomes, and on positive changes in employee and organizational culture. 

Development of E-Transitions Tools for Home Health Care

This project, conducted jointly with Weill Medical College of Cornell University, evaluated the impact of a redesigned and automated CMS 485.

Collaboration for Homecare Advances in Management and Practice (CHAMP)

This program addressed a series of interrelated problems that had led to suboptimal geriatric care for many home health care patients and took advantage of a changing environment that had created stronger incentives for home health agencies to put quality of care for this patient population at the top of their strategic goals and priorities.

Home-Based Blood Pressure Interventions for African Americans (HTN Study)

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 BP control among an especially high-risk population, African Americans receiving home care.

Palliative Care and Hospice Consultation

The "PCC" project was designed to provde non-hospice patients in VNS Acute Care with the social emotional and physical support necessary to manage pain and confront the relaties fot he their illnesses.

Early Head Start Fatherhood Initiative

The project’s objectives were to assist in the reduction of infant mortality throughout the Far Rockaway Community as well as  to increase paternal participation in childrearing among other objectievs.

Partnership for Advancing Quality Homecare (PAQH)

This project launched a national partnership among home health care providers to improve care for a priority population--elderly home care recipients. 

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

This project designed and pilot tested an information-based hospital-home care transition intervention intended to improve care and outcomes for heart failure patients. 

Working Conditions & Adverse Events in Home Health Care

The goal of the project was to describe the relationships between and among key features of the organizational work place, the nursing work force and adverse events due to preventable errors in the home health care setting.

Patient Safety in Home Care: Developmental Center for Evaluation and Research in Patient Safety

The goal of the partnership was to enhance the intellectual resources, disciplinary skills, measurement tools and organizational techniques for understanding and teaching about medical errors in home health care and designing and evaluating mechanisms for learning from such errors and reducing them.

Early Head Start

The VNSNY Early Head Start Program is a comprehensive child health and development program serving 75 pregnant and parenting teens and their infants and toddlers in Rockaway.

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

This initiative had two main objectives. First, it assessed the current knowledge base for supporting home health care quality improvement to identify ways to improve its relevance and accessibility. Second, it developed a model for collaboration among home health care providers and researchers to improve quality performance.

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

The study was conducted in three phases over a three-year period. Phase I focused on prospectively identifying and recruiting adult home health recipients with two of three tracer conditions (congestive heart failure, joint replacements, or surgical wounds).

Black Elders in Home Care: Contributors to Successful Recovery

The purpose of this study was to understand how and why recovery rates differ between black and white elderly patients at VNSNY, so that the information gained can be used to improve the provision of care and patients' outcomes.

Evidence-Based E-Mail "Reminders" in Home Health Care

This project tested the relative effectiveness and cost-effectiveness of alternative information-based strategies designed to improve provider performance and promote adherence to evidence-based practice guidelines among home health care nurses.

Home Health Outcomes Assessment Initiative

This project was designed to support additional data collection, analytic work and preparation of informational materials under VNSNY’s Home Health Outcomes Initiative. 

Transitions Among Post-Acute & Long-Term Care Settings

The study also aimed to identify events that might indicate problems with transitions and the frequency with which these events occurred.

Implementation and Evaluation of Health Outcomes Management and Evaluation (HOME© Plans) for HomeHealth Patients with Diabetes

The New York State Health Services Quality Improvement (HSQI) Grants Program provided funding for continued assessment of a multi-faceted improvement strategy centered on home health protocols of Health Outcomes Management and Evaluation (HOME©) Plans (PHASE 2) designed for specific high-cost, high frequency chronic conditions.

Preferences for Everyday Living Inventory (PELI) Project

This study sought to pilot-test a questionnaire that would capture elders’ preferences for everyday living. 

The Bridge Program: Effecting a Successful Transition from Hospital Emergency Department to Treatment at Home

This was a planning grant for a pilot project to test the feasibility of a collaborative home care/hospital project to avert unnecessary inpatient hospitalizations among elderly patients presenting at a hospital emergency room

Review of Assessment Instruments for Individuals Receiving Home-Based Long-Term Care

The Center convened an Expert Panel to explore how consumer and family preferences could be incorporated into the care planning process.

Improving Pharmacotherapy in Home Health Patients

The objective of the study was to develop guidelines for improving medication use in home health care and to test the efficacy of an intervention using these guidelines in a randomized controlled trial.

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

The objective of this study was 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.

Developing a Survey of Consumer-Centered Community Care

The objective of this joint project with the Picker Institute of Boston was to develop a survey instrument that could be used to measure the key dimensions of high quality community care from the consumer's perspective.

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

The objective of this study was to assess the feasibility and efficacy of using videophone reminders to increase medication compliance among elderly CHF patients.