Clustered Care Model Thrives Under Home Health Partnerships

Through a collaboration among home health aides, social workers and building management, one New York non-profit has been able to successfully help older adults age in place via its “clustered care” model.

The Visiting Nurse Service of New York (VNSNY) provides home and community-based care to the city’s booming senior population as part of its Congregate Care program.

What’s unique about the program is that it follows a “clustered care model,” where home health aides often care for multiple residents at a time, says Rhonda Soberman, manager of program development for the Congregate Care program.


The home health aides for VNSNY’s program are provided Partners in Care—a subsidiary of the organization—that enables flexibility not only for workers, but for the residents as well, says Soberman.

“The cluster aide model enables us to stretch the care for people to provide more services when they need them, instead of providing care in blocks of hours,” she says.

Some of the services Partners in Care provides include assisting residents with activities of daily living, such as bathing, dressing, preparing meals and ambulatory services, says Sal Bastardi, director of certified services at VNSNY.


“The aides are a lifeline for the residents,” says Bastardi. “Whether they are handling a multitude of patients in a day, they help give residents a sense of community and care.”

The aides are trained for specialized care for residents with Alzheimer’s, diabetes, stroke and cardiovascular diseases, they do not provide medical care. This is where VNSNY’s visiting nurse comes in handy.

Each VNSNY building has a registered nurse that provides a wide range of services, including wound management, infusion care, hospice and transitional care post-hospitalization.

In the Congregate Care division, according to Soberman, each facility has at least one registered nurse on site daily, providing care to any resident who walks into the nursing office.

These nurses also take on roles as educators, holding workshops on an array of topics such as fall prevention, managing high blood pressure, how to manage multiple medications, and diabetes, to name a few.

“Part of the nurses’ role is encouraging people to be proactive about their health so they can prevent issues that could possibly be more extreme,” says Soberman.

The profile of a typical resident served by VNSNY varies, as no two residents are really the same, suggests Soberman.

“Different buildings have different people,” she says. “Some might have people with chronic illnesses, some of them might even have multiple chronic conditions and may need ongoing care.”

While VNSNY does not charge residents for the services they provide under the Congregate Care program, the organization receives funding from Medicare, grants and even philanthropic entities, says Soberman.

The organization also offers six health plans to its residents covered by VNSNY CHOICE, which include three Medicare Advantage plans, two long-term care plans, and more recently a VNSNY CHOICE SelectHealth—a plan for individuals living with HIV/AIDS.

The largest not-for-profit home health provider in the United States serving an average 30,000 individuals on a daily basis, VNSNY sees a continued demand for its services.

Although VNSNY’s services are not reserved only for seniors, there is growth to be had in the city’s aging population.

In 2010, New York City’s elderly population of adults ages 60 years and older numbered 1,407,635, representing 17.2% of the city’s population, according to the New York City Department for the Aging (DOA).

The city’s age-85 and older population is growing rapidly at 16.2%. Moreover, there has been a dramatic increase among the younger elderly ages 60 to 64 (31.9%), and this trend will continue in the years ahead as baby-boomers age, the DOA notes.

“Being in these types of communities and being able to support our partners is very important, because people don’t have needs that are just in one area,” says Soberman. “Through Congregate Care, we’re providing an important piece of the puzzle in these communities.”

Written by Jason Oliva

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