Homecare for the 21st century

VNA Private Care is designed to meet the needs of elders and families through independence and a balanced life

VNAPC clinical manager Betsy Cunningham, RN, (right) reviews meds with client Carol Farley in Carol’s home. (David Stone for On Call)

The conversation is in the air in every workplace and social gathering: "How can we take care of Mom? We live across the country; we're raising teenage kids, and we work 50 hours a week." Nationally, more than 15 million adult children are taking care of their parents. In Massachusetts, there are over 650,000 family caregivers for elders or disabled relatives, and 63 percent hold part- or full-time jobs.

The combined realities of elders with chronic medical conditions living independently and their baby-boomer children looking for customized solutions to complex medical, psychosocial, and economic issues is what led VNA Private Care (VNAPC) to develop a pioneering model of homecare. VNAPC, an affiliate of Visiting Nurse Association of Boston (VNAB), helps elders who wish to remain in their homes for as long as it is safely possible maintain their independence and optimal health. VNAPC collaborates with clients and family members to provide a continuum of services that meet personalized goals while at the same time helping family caregivers find balance in their lives.

John Paul Marosy, executive director of VNAPC, says, "The demands on people's time are phenomenal. Family members are very rushed, and VNAPC recognizes the emerging need to meet the full spectrum of care in the community." While VNAPC specializes in elder care, their services are available to most adults, who choose to pay privately or with long-term-care insurance.

The VNAPC model of care

Betsy Cunningham, RN, is clinical manager of VNAPC. She oversees all direct-care services and serves as a geriatric care manager on selected cases. Cunningham says all care at VNAPC is supervised by an RN who is available 24 hours a day. In a mutually beneficial arrangement, all CNAs and nurses are employed by VNAPC and receive benefits as well as continuing education.

VNAPC has the unique ability to offer a comprehensive continuum of care that family members can access by working with VNAPC sister agencies. VNA of Boston can provide physician-prescribed care during acute episodes or access to treatment by an occupational therapist, physical therapist, or speech-language pathologist. As a person nears the end of her life, she can be transitioned to the expertise of VNA-affiliated hospice. Marosy says, "From the family's point of view, not having to do research when anything changes is a huge time saver and stress reducer. They know they can rely on us to make the transition."

Mapping out a plan of care

When a client or family contacts VNAPC, the nurse and a social worker or geriatric care manager visit the home. There, they do a comprehensive assessment of the client that identifies all medical conditions, sensory deficits, functional abilities, and medications. They survey the safety of the environment, looking for rugs or poor lighting that could lead to falls and for the presence of safety features such as grab bars. They encourage the client to update legal documents, too, including healthcare proxy, power of attorney, and advance directives.

Cunningham says that after assessing the situation, they ask family members, "Have you thought down the road? Do you have a plan in place as your Dad's needs change?"

This leads to a detailed care plan and an agreement on services to be provided by direct-care staff or, at another level of service, geriatric care managers.

VNAPC can arrange for a dentist, podiatrist, geriatric psychiatrist, or elder-care attorney to make home visits. They also maintain a network of home-repair contractors and organizers.

Geriatric care managers: overseers, experts, and advocates

After contacting VNAPC, family members can contract for the professional services of a geriatric care manager (GCM). The GCM specializes in researching and explaining information, tracking changes and arranging services, mediating among family members, and advocating for the health and welfare of the client.

Renee Parris Brown, RN, MS, geriatric care manager, emphasizes that part of her role is to look at global aspects of elder care, including health, finances, and legal issues. She can also go to physician appointments and communicate details back to the family. Brown says, "It carries weight when a professional advocates for the person."

Brown's perspective is informed by her extensive background in clinical and administrative positions in private and community-based elder-care organizations. Brown is particularly interested in assuring that her clients receive top-notch, coordinated medical care that treats the whole person and reduces the risk of polypharmacy. She researches physicians' backgrounds to verify credentials, and she can take on a leadership role in coordinating multiple specialists.

Carol Westheimer, MEd, LMHC, says that, increasingly, adult children want a professional to provide oversight of the entire situation and to assist in decision making. That professional needs to decipher information and make recommendations for additional services. The care manager's role is to have a wealth of information on housing alternatives or medical resources and to help the family extrapolate what is in their best interest.

Communication is key to the job. So the care managers call, email, or send reports with specifics about how the elder is changing, steps to take to prevent a crisis, and additional services needed.

Westheimer is certified as a preferred provider of the Alzheimer's Association. She says that during a home visit, she might find that the client's congestive heart failure is controlled, but behavior is an issue. In that case, she can arrange neuropsychology testing and craft an individualized plan based on the results.

Westheimer points out that dementia care requires constant fine tuning, training for CNAs, and team communication. VNAPC offers a memory care team to work with elders who have dementia or Alzheimer's disease. Cunningham makes sure that the care providers are carefully matched with clients and well versed in skills and strategies to help them feel safe and understood.

Expanding definitions of wellness

Many of the services offered by VNAPC bring qualified care providers into the client's home or assisted-living facility to administer direct care. Cunningham emphasizes that these CNAs are their eyes and ears and often spot potential problems early. They complete a shift report in a communication book kept in each client's home.

Returning home after day surgery, an acute hospitalization, or rehab can be anxiety-provoking and potentially dangerous for elders. The "safe transition to home" program offers customized services to help with transportation, personal care, meal preparation, and coordinating prescriptions and supplies.

Other services are designed to address our expanded understanding of what contributes to good health and well being. Snowbird services, for instance, offer Florida-bound Bostonians the security of a medical network and personalized home care through partnership with an agency in Florida.

Marosy describes the dream of an elderly gentleman who has chronic obstructive pulmonary disease and wanted to spend the winter in his Florida condominium, but was afraid to fly alone due to his medical condition. VNAPC arranged for a CNA to help him pack, accompany him on the flight, settle him into his condo, and transition his medical care to the Florida agency. Within a week of making the initial call, he was basking in the Florida sun.

Westheimer says that in recent years she has seen a shift from families arranging basic health care to an increased interest in supplemental services that enhance quality of life. "Maintaining favorite activities can make a huge difference in level of functioning," she says. "It improves memory and boosts state of mind." She recalls an 80-year-old woman who had attended Boston Symphony Orchestra concerts since she was16. Realizing the importance of this tradition, the family hired a VNAPC cultural companion to accompany her every Friday afternoon to Symphony Hall.

Benefits for family caregivers

Jane Achterkirchen has a first-hand perspective on all these issues. Achterkirchen lives in San Francisco, but collaborates with her sister in the metro Boston area to arrange care for their mother, Mrs. B., who lives in a Boston suburb. Achterkirchen says, "The family feels desperate when a beloved older person can't be alone anymore." Following a hospitalization for a fall and fractured hip, Mrs. B. has been back in her home and regaining functioning with CNAs from VNAPC providing round-the-clock care for two months.

"If something comes up at 3AM, the night aide can discuss it with the covering RN right away," says Achterkirchen. "It's like having an advocate who is an extension of your family." When Mrs. B had severe back pain, the CNAs and nurses persisted in requesting further evaluation with the MD until the source of the pain was identified and treated more effectively. Achterkirchen sums up what VNAPC offers in one word: Hope. She says, "My mother was completely hopeless, and thought she was at the end of her life." Since the nurses and aides advocated for her and showed her how to manage and move, Mrs. B. is gaining strength and pleasure in life.

"VNAPC gives the client and family hope and peace of mind," says Achterkirchen.

Janet Cromer is a freelance writer and regular contributor to On Call. She is a recipient of the 2008 Will Solimene Award for Excellence in Medical Communication. She received the award for her three part series on medical humanities in Boston area hospitals that appeared last year in On Call.