The Center's research focuses on four main areas to:

1. Improve the quality and outcomes of health services at home.
2. Help people better manage their chronic conditions.
3. Analyze and inform public policies that affect home-based care and access to long-term care.
4. Support communities that promote successful aging in place.

Improved Quality and Outcomes

VNSNY’s commitment to providing high-quality care requires that patient managers and clinicians have timely access to accurate, complete patient information as the patient progresses through the care process. The Center’s Division of Outcomes, Informatics and Evaluation, launched in 1996, supports VNSNY’s quality improvement efforts through research, evaluation, and the management of a state-of-the art patient information system. The Outcomes Group ensures that appropriate patient data is accurately collected, analyzes patient data, stores this information in a data warehouse, and generates customized reports to track trends and changes in patient progress over time.

Outcomes researchers, working hand in hand with patient managers and other VNSNY staff, evaluate new clinical, business and workforce programs and initiatives and measure their impact on quality and patient health outcomes. The Outcomes Group is currently assessing how the use of remote monitors in patients’ homes affects patient care and health outcomes.

Much of what the Outcomes team has learned is already in practice at VNSNY: They have developed statistical models to predict which patients are at risk for hospitalization, for example, and the capacity for nurses to get automatic email notification when new patients are deemed to be at risk. The researchers have also created an analytic tool to predict whether new home care patients will be discharged from home care or need referrals to other VNSNY programs. An internal website, developed by the Outcomes team to give appropriate VNSNY staff access to patient information and quickly create customized reports, has become integral to VNSNY practice.

VNSNY is devoted to home care excellence based on solid evidence. The Center’s Outcomes Group–with a capability that is unique in the home care field–provides that evidence, making it the underpinning of quality improvement efforts and new initiatives and programs at VNSNY.

Better Management of Chronic Conditions

In VNSNY’s service regions and across the U.S., young children, adults, older persons and their families are learning how to live with complicated chronic health conditions, such as diabetes, cancer, heart disease and hypertension, that can be treated effectively at home. Often, these conditions require significant lifestyle changes and adherence to complicated medical regimens. In collaboration with national experts and VNSNY clinicians, the Center’s staff is testing ways to help our patients and their families manage their chronic conditions in order to stabilize their health, prevent unnecessary hospitalizations and improve the quality of their lives.

• The Home-Based Blood Pressure Interventions for African Americans study, finishing up in 2010 with funding from the National Institutes of Health, is one such initiative. Approximately eight percent of all home care patients have been diagnosed with hypertension; African Americans receiving home health care are known to be at heightened risk. More than 325 nurses and 845 patients participated in this study, which was designed to examine the effectiveness of two interventions aimed at improving blood-pressure control among African Americans in home care. The final results will be ready in the summer of 2010, but we already know that patients in the program find that focusing on managing their blood pressure allows them to feel more confident about their ability to manage their health, in general.
• Patients’ ability to self-manage their health and health care–and their nurses’ ability to support them and their families in this effort–are critical to improving the quality of care and health outcomes for people living in the community with chronic health conditions. In studies supported by the Agency for Healthcare Quality and Research and by the Robert Wood Johnson Foundation, Center researchers are working with researchers from Weill Cornell Medical College to investigate what circumstances, which educational interventions and what types of support can facilitate “activated” patients who have the necessary knowledge, skills and confidence to better manage their chronic conditions and keep their illness from getting worse.

Informed Public Policies

We seek to foster equitable and cost-effective policies for home and community-based care by analyzing, understanding, and disseminating information on how the government pays for, measures and regulates post-acute and long-term care. Our studies aim to show how public policies influence access to services, and the use, costs, and outcomes of care.

• The Center is conducting research to examine how Medicare, the federal government’s health insurance program, pays for and assesses the quality of home health services. Researchers are looking at new ways to measure home care quality that accurately reflect differences in the health status and needs of chronically ill patients, who require longer-term home health care, and patients with post-hospital recovery needs, who may need shorter-term home care services. The findings from this study will help the Centers for Medicare & Medicaid Services (CMS) and other federal agencies to monitor and improve home health care quality, while minimizing the data collection and reporting burden on home health agencies. “Assessing Home Health Care Quality for Post-Acute and Chronically Ill Patients” is funded by the Office of the Assistant Secretary for Planning and Evaluation (ASPE), a federal agency.

Successful Aging In Place

The Center works with communities to assess their preparedness for a growing elderly population and to help them plan for “elder-friendly” communities that support residents’ ability to remain in the community as they age.

• The AdvantAge Initiative is a long-standing Center project that works with communities large and small to help them measure their elder-friendliness and plan for a population that is growing older. The AdvantAge Initiative’s planning tools include a framework for an elder-friendly community, a set of 33 indicators of elder-friendliness, and a comprehensive survey questionnaire that is administered to measure how well older people are faring in their communities. The data from the survey are then used to facilitate a planning and action process designed to respond to older adults’ most pressing concerns and needs. The AdvantAge Initiative has been administered in 26 communities around the country and in the entire state of Indiana, the first state to adopt the AdvantAge Initiative and engage in a statewide planning process.  For more information, click here to visit the AdvantAge Initiative website.

The Center’s researchers collaborated with the “Aging in Place Initiative” of the United Hospital Fund to develop a set of indicators that can be used by “Naturally Occurring Retirement Community Supportive Services Programs”(NORC-SSP’s) to identify health risks among residents aged 60-plus. The Center’s researchers administered a survey to residents being served by the New York City NORC-SSP’s to identify health risks. Over the course of this three-year study, the research team has built a database and system to administer the questionnaire to residents of all 54 New York State NORC’s. The data are now being analyzed to identify and prioritize health risks so that practice guidelines and evidence-based interventions can be implemented to diminish these risks. The Center’s researchers will re-administer the full survey to measure any changes from the initial findings during the final phase of the study, which ends in 2010.