Helping Seniors Manage Chronic Health Issues at Home

by Marki Flannery, Former President and CEO

It was the cough that first alerted a caregiver checking by telephone on Brenda, an 82-year-old retired school librarian living with COPD, asthma, diabetes, hypertension, and other chronic illnesses. Brenda’s home health aide joined the phone call and noted that her client’s chilly apartment seemed to prompt the cough. As the home health care team continued to confer with Brenda, they soon uncovered that the retired librarian did not understand her medications, was reluctant to use her nebulizer, and couldn’t afford a space heater to warm her persistently cold apartment.

Following up, an RN clinical care manager from the Visiting Nurse Service of New York proceeded to connect Brenda with the comprehensive care she needed, in the place she needed it most: her home. The care manager educated Brenda on the importance of proper nebulizer use, helped her manage her medications at home once the pulmonologist revisited her prescriptions, and reached out to a family member who was able to provide a space heater.

It is exactly this kind of home-based comprehensive care management, which considers the patient’s entire life and puts patient education and empowerment at the center of care, that is leading us—right now—into the future of health care.

Why the Home is the Health Care Hub of the Future

The fast-growing home care industry—expected to grow 54% by 2026—is evolving to meet the challenges of how Americans age today.

More than one-quarter of US adults have been diagnosed with multiple chronic conditions, including hypertension, cancer, stroke, coronary heart disease, heart failure, diabetes, arthritis, hepatitis, asthma, kidney disease, and/or chronic obstructive pulmonary disease (COPD). Often, having one of these conditions makes people more vulnerable to others. Half of people diagnosed with heart failure have five or more additional chronic conditions, for example, and 40% of those with diabetes also have three or more other conditions.

For Brenda—and the millions of other older Americans living with multiple chronic conditions—managing their health is a daily endeavor, and one that takes place primarily in the home.

In recognition of the way Americans today are aging and consuming health care in the home, we’ve launched a new care management organization (CMO) at VNSNY, called VNSNY Care360° Solutions, which works with insurers to provide extra support to people living with seven or more chronic illnesses. We work proactively and preventively to help these individuals manage their many conditions and symptoms at home, support their physical and behavioral well-being, and avoid a downward spiral in health that can lead to the frequent and unnecessary trips to the hospital and other acute-care settings that exact such a high financial and human toll.

Keys to Health: Readiness and the Confidence to Change

When it comes to treating chronic conditions, the goal is not to cure them—since these conditions are often uncurable. Rather, our CMO’s health care approach centers on making and maintaining lifestyle changes necessary to manage our clients’ symptoms, improve their quality of life, and avoid preventable hospitalizations.

“When we look at someone’s ability to cope with chronic disease, we look at their ability to make changes in their lifestyle—whether that’s a patient with COPD quitting smoking or using nebulizer on a regular basis, or a patient with diabetes who is able to change their diet, monitor their blood glucose carefully, or take insulin properly,” says Rose Madden-Baer, VNSNY’s Senior Vice President for Population Health and Clinical Support Services. “To evaluate this, we look at two key parameters: their readiness to change, and their confidence that they can change.”

Of course, change can be difficult for an older person, especially after years (and sometimes decades) of unhealthy habits. But with the right support, it can be attainable. VNSNY’s CMO uses specific evidence-based methods to assess patients’ readiness and confidence to change. Our specially trained clinicians then employ motivational interviewing to engage patients and help them overcome challenges.

Once Brenda understood the importance of the inhaler for delivering medicine directly to her lungs, and also understood how the cold, dry air of her apartment could irritate her lungs, she became more motivated to follow her plan of care. She also saw how helpful it would be to get a family member more involved in her care. That family member now helps Brenda manage her medications and knows to alert the care team if she shows signs of depression or anxiety—common comorbidities in COPD and other chronic illnesses.

Turning Advice into Action

Home health care, properly administered, enables patients living with chronic illness to bridge the gap between receiving advice at the doctor’s office or clinic and following that advice when and where it matters most: in daily life at home. For example, if someone with diabetes and heart failure lives in a neighborhood that only has fast food restaurants or they face food insecurity, we connect them with organizations that can provide them with fruits and vegetables. If someone has COPD, we’ll connect them to smoking-cessation resources, help them understand environmental triggers in their home, and educate them on proper inhaler and nebulizer use.

Because chronic illnesses are part of the ups and downs of daily life, setbacks can happen. Hypertension and diabetes don’t take a holiday. Overindulging, whether at a birthday party or holiday dinner, not only can elevate sugar levels and even result in a hospital visit but can also undermine that person’s hard-won confidence to successfully manage their condition. For this reason, we regularly reassess how confident and competent our patients are—and remain—in making the right dietary choices, following their care plan, getting to doctors, managing their medications, and monitoring their symptoms.

“We are constantly tuned in to how engaged people are, and how we can help them continue to feel confident and in control,” says Rose. “When it comes to living within the guardrails of chronic illness, it’s all about empowering people in their home setting, by helping them understand what they need to do each day—and then supporting them in doing it.”

I’m proud to celebrate my colleagues and fellow innovators in the field, and to renew VNSNY’s more than 125-year-old commitment to supporting and empowering the most vulnerable among us. Tradition may say that “home is where the heart is,” but as we look ahead, what the future tells us loud and clear is that “home is where the HEALTH is.”

VNSNY can help you provide the best care to your patients. Find out how today.