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Home Care Takes a Team

home care nurse marie“In home care, it takes a team to care for a very sick patient,” says VNSNY Home Care nurse Marie D. “And at the center of that team, helping to keep everyone connected, is the home care nurse.” Marie speaks from experience: A home care nurse in the Nassau County region, she has been a registered nurse for 26 years, the last 18 of them with VNSNY. During that time, she has seen every type of patient, from those who are discharged after a number of weeks to cases where she and her colleagues provide essential care for months and even years.

One longtime patient she has grown especially close to is Jean*, a Long Island resident in her 50s with multiple sclerosis. Following Superstorm Sandy in 2012, Jean was immobilized for days without electricity. She developed a pressure ulcer so severe that when Marie was finally called in to assess her, her physicians were pushing to have her hospitalized. “Jean was terrified at the idea of going to the hospital, so I convinced her doctors to let us try treating the wound at home,” Marie recalls.

Marie began visiting Jean daily, employing a chemical debridement agent to clean out the wound and remove the dead tissue—an essential first step in the healing process. Finally the wound reached a point where it began healing, and Marie was able to scale back her visits to three times a week, constantly assessing Jean’s condition and calling the doctors for new treatment orders. As Jean progressed, Marie also brought in a physical therapist and an occupational therapist to help Jean regain strength and functional ability.

As the team member who performs initial assessments and typically coordinates the patient’s services, Marie is “the bridge” in the home care process, as she puts it. In addition to providing direct treatment, the job of home care nurse includes making referrals to therapists, social workers, behavioral health nurses, and home health aides—whoever might be needed to help patients manage their health and return to a state of independence.

Educating patients and their families is another critical part of the home care nurse’s role. “The goal is to form a partnership with the entire family,” Marie explains. During every visit, Marie reviews all instructions to make sure everyone understands them. She also teaches patients about their medications, healthy eating, the value of health screening and flu vaccines, proper syringe disposal, and the importance of sticking to a prescribed medical regimen and making follow-up visits to doctors. “Seeing a patient become able to name all their medications and what they’re for, and begin to participate in their own care, is a wonderful feeling,” adds Marie.

Marie is proud to have been among the original nurses who helped launch VNSNY’s services in Nassau County back in 2003. “It was like a little family,” she says. “Since we were only five nurses at that time, we had to cover the entire county. We would have to plan our route before starting out for the day, so that we could manage our time going from home to home wherever we were needed.” Today, VNSNY’s presence in the region is large enough that Marie is no longer surprised to see the face of a new colleague she hasn’t met yet. That state of affairs never lasts long, though—in fact, newly hired Nassau nurses often shadow her to learn the nuances of home health nursing. “It’s something I really enjoy doing,” says Marie. “I love having the chance to show them what home care is all about.”

As for her patient, Jean, after two and a half years of steady treatment, her wound finally healed completely. Today, she is back in Marie’s care for a recent, less severe wound that is healing well, and she continues to work regularly with a physical therapist and a psychiatric nurse from VNSNY. She also has a home health aide from Partners in Care who takes care of her daily needs such as bathing and dressing. “Our entire team goes above and beyond for the benefit of the people we serve,” says Marie.

“Marie got me to heal after the doctor had told me that he didn’t believe it was possible,” adds Jean. “She did it.”

* The patient’s name has been changed for privacy.

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