Delivering Multifaceted Medical Care to the HomeboundFriday, June 10, 2011
Versed in dealing with a variety of ailments and medical conditions, Yael Reich (pictured), APRN, MSN, CDE, BC-ADM, and the Visiting Nurse Service of New York (VNSNY) are trained to administer and coordinate care, educate, and provide comfort to their homebound patient clients.
By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net
An elderly parent living alone has fallen or they have ended up back in the hospital again fighting the complications of a chronic disease like diabetes. After a short stay, the parent will be discharged, but mom or dad is going to need additional care at home. Yet, the parent’s adult children live far away and cannot leave their homes to care for the parent.
In situations like this, adult children can suffer a great angst if they cannot be present for a parent who has chronic health problems and may be homebound. It is this very fear, which visiting nurse services look to alleviate.
Visiting nurses bridge the geographical distance for families, serving not only as a medical professional but often as a friendly face for those in need.
Whereas Florence Nightingale was armed with a lamp administering to soldiers, today’s visiting nurses carry their cell phones and laptops while serving in the field.
One such organization that is committed to this traditional, and vital form of nursing is the Visiting Nurse Service of New York (VNSNY). As an organization, VNSNY covers the metropolitan New York City area, suburban Westchester County, and Nassau County on Long Island. The organization has been in existence since 1893.
Just last year, VNSNY made 2,428,000 home visits, caring for 140,000 patients, and provided $27.5 million in charitable services to the uninsured or underinsured New York citizens. Along with their visiting nurse service, they also offer programs like home health aids and physical therapy.
Yael Reich, APRN, MSN, CDE, BC-ADM, is one nurse and diabetes educator from the organization. Reich (pictured here) has spent several years out in the field and now is a diabetes clinical specialist for VNSNY. The company’s clientele consists of approximately 30,000 people with diabetes. And with just three CDEs, including Reich herself, together they have a huge task in educating the 2,600 VNSNY nurses about diabetes self-management, so those nurses can go out and teach their patients about the disease.
Reich is one of the organizers of continuing education classes for VNSNY and its annual Elaine Edelstein conference. She coordinates diabetes care with individual patients and teaches self-management seminars at community centers.
DiabetesCare.net recently caught up with Reich and she discussed some of the joys and challenges associated with treating patients with diabetes in home care settings:
DiabetesCare.net: How did you first decide to become part of the VNSNY?
Reich: During my student nursing years at Columbia, I had a rotation for community health at VNSNY. Even as a student, I thought this was the direction I really wanted to purse. I felt the individual care of the patient at home would be a very fulfilling career. I worked in a hospital for about a year after graduation, and in 1993, I started as a visiting nurse in the field at VNSNY.
DiabetesCare.net: Can you provide an overview of what a day working at VNSNY might entail?
Reich: A typical nurse who works in the Adult Care program―which is the biggest program we have― would have a laptop and get information about patients sent to her.
The nurses see about six patients a day, and their territories are usually in a limited area or neighborhood. Nurses see a variety of patients including those who have wounds to those who have had a heart attack or surgery or diabetes, or long-term conditions who have been confined to home. The nurses really have to provide the care according to what the condition is.
The nurses coordinate the care of all the services we provide. Everything we do in home care has to have a doctor’s signature on it. Nurses have to constantly communicate with the doctor to establish the plan of care for the patient at home.
Nurses don’t have to carry many tools with them. They order the necessary equipment, tools, and bandage dressings that they need to have the patient stay safe at home.
DiabetesCare.net: Can you talk about your role within the organization?
Reich: My role as a diabetes educator is to provide educational support to nurses, patients, mangers, community organizations. A lot of my time is spent with nurses talking about the issues related to diabetes. We have team meetings and provide different topics. In addition to that, I consult on individual cases of patients at home who have uncontrolled diabetes. Nurses consult with me about what they can do to improve the overall health of that patient.
In difficult cases, I do joint visits with the nurses. Also, when I get a child with type 1 diabetes, and the family needs a lot of support and encouragement, I do make a visit.
We also write and have published self-management booklets and nutrition guides with tools that can be brought to the patient.
DiabetesCare.net: What are the challenges you are seeing in applying care to such a large population of people with diabetes?
Reich: One of the biggest challenges we see in homecare is that patients do not take the medication. Another issue we see is that medical providers are sometimes reluctant to prescribe enough medication. Maybe the patient had one episode of hypoglycemia in the past, so the doctor is reluctant to increase the dosage. Sometimes patients stay in a hyperglycemic state for many days and months. We try to teach the patient self-management and what the side effects are, and titrate the medication, with the doctor’s permission of course.
DiabetesCare.net: What are the benefits of practicing home care medicine?
Reich: It is a very rewarding job. We really help patients in their home and in the community. We provide a lot of one-to-one education to the patients and we can see great results. We think that home care is where the rubber meets the road. This is where education can really happen. In the hospital, often the patient is not usually well enough to receive the education. The patient might be taught how to use an insulin pen there, but he or she may forget because they were thinking about all the issues associated with the disease. We feel education can really take place in the home environment. We see tremendous changes in behavior and improvement in patients’ diabetes conditions at home.
We have developed several programs over the years including diabetes classes in community centers. We have seen improvements in A1c through lifestyle changes.
DiabetesCare.net: Does VNSNY have any specific diabetes programs for your nurses or community centers?
Reich: We are nearing the end of the application process for diabetes education certification with AADE to become an approved program. It is titled the Diabetes Community Program, which is for community centers, and we already ran a pilot. We created the program but followed AADE standards. Once you become an approved program you can charge for your services. We are planning to have a program in each of the five boroughs of New York City that are delivered in senior community centers.
In terms of teaching our nurses, we have several programs that we have been running through the years. We now have e-learning. Nurses are required to do four hours of education via their laptops. When nurses start at VNSNY, they have a program that shows what a visit with a patient with diabetes entails and what the nurse must do. In addition to those things, we have other presentations and tests that we do on a regular basis.
DiabetesCare.net: Do many of your patients have family members who live far away and cannot be nearby to care for their loved ones?
Reich: Yes, but we see every variety under the sun. We have people that live alone in an apartment, and patients who live with family. Nurses need to learn how to navigate through all these variables to provide good medical care. The difference between home care and providing care at a hospital, private practice, or clinic, is that the nurse is in the patient’s territory. You are a guest in their home and you have to adapt to their environment and provide good care for them on a one-to-one basis.
DiabetesCare.net: For patients that are uninsured or underinsured, but need additional care, what can VNSNY do in terms of follow-up care?
Reich: We have a very good social service department, and we try to hook them up with insurance and continue the care. Sometimes, we take care of people who are not even eligible for those insurances.
We give 10 percent of our income back into the community by giving charitable care.
DiabetesCare.net: You are an Elaine Edelstein conference organizer. Can you explain what that conference is and what you do for the event?
Reich: Elaine was our first diabetes educator at VNSNY, and she passed away in 2005. She was very active in promoting diabetes education to home care nurses. She helped me to become a diabetes educator. To honor her, we decided to have a conference in her name. Every year we have a different topic. It is not just for VNSNY nurses, it is open to the public. It is a free four hour conference that we concentrate on different topics. This year’s topic is “Diabetes Through the Lifespan.” Last year, we did “Diabetes Complications We Don’t Talk About.”
We also give an award to a nurse or healthcare professional who specifically changed the life of a diabetes patient or has done some extraordinary achievement in the organization.
To learn more about the VNSNY, go to www.vnsny.org.