03/29/2013 02:11 pm ET Updated May 29, 2013

Home Health Aides: Clustered Together for Better Care

Home health aide Elaine Bigio came to work one recent morning in a large public housing building in New York's Washington Heights neighborhood. She knocked on Isabel Rodriguez's* door, prepared to fix breakfast and get her 80-year-old patient's day going.

There was no answer. Elaine was worried but knew she had somewhere to turn for help. She took to the halls of the sprawling apartment building and quickly found veteran home health aide Altagracia Javier, who knocked on the door and called out to the patient. Finally, the two aides heard a faint, "I can't get up."

Mrs. Rodriguez, who suffers from dementia and is anxious about answering the door, had fallen overnight and broken her hip. She recognized Altagracia's voice because Altagracia had previously been her aide for many years. The two aides called another colleague in the building, who called 911 while Elaine and Altagracia contacted building security -- the team was in motion.

This kind of teamwork is unusual among home health aides, who after their initial training often work in isolation, dispersed throughout individual households. But the public housing complex where they work is a congregate care facility that brings home health care and education directly to the residents who live the building. This model of "clustered" home health aide care also includes on-site nursing staff and is ideally tailored to the way we live and age in urban environments today.

A Community-Based Model
In this seniors-only building, many residents suffer from multiple chronic conditions, particularly diabetes, congestive heart failure and chronic obstructive pulmonary disease (COPD), mirroring a national trend across an aging America. At the same time, sweeping health care reform, including changes in long-term care structures, means that many patients have recently seen their allotted hours of home health aide care cut down. The cluster system provides solutions for both aide and patient. For the aides, this model means they can cluster together several clients in a single place, putting together shifts of, say, two or four hours a piece with a commute as short as an elevator ride.

For the patients, there is peace of mind in knowing that even when their aide finishes a shift, there are still many watchful eyes and ears in the building. When her home health aide leaves after the regulated four-hour shift, Aida Lopez, who suffers from dementia, heads across the hall to watch television with her neighbors. That couple's aide keeps an eye on Mrs. Lopez as well, as she passes the afternoon safe and in good spirits because she has company.

"If these patients spend too much time on their own they can start to go downhill quickly," says registered nurse Claudette Bourque, a coordinator of care in the building. Though she mans a second-floor office here, Claudette can often be found walking the halls, checking in on residents to make sure they don't get caught in that downward spiral of isolation, depression and anxiety. "If I peek my head in and see someone who's not up yet and it's the middle of the day, I'll call in an aide, we'll get him out of bed, get him freshened up and out for a little air."

This home health aide cluster system works hand in hand with VNSNY's Congregate Care program, a community-based model that serves more than 338 housing sites throughout the Greater New York City area. A dedicated nurse like Claudette is assigned to the housing location and, in addition to seeing patients who are enrolled in VNSNY CHOICE Medicaid Managed Long Term Care, she provides all residents with access to health education and information, blood pressure screenings, flu shots, and other health services and resources. The model focuses on prevention and helps active seniors remain healthy and connected to their community, leading to a greater sense of independence and well-being.

Good Neighbors, Good Coffee, Good Care
Stop by the fifth floor any afternoon around 3:30 and you'll smell coffee brewing and hear the buzz of conversation and laughter coming from the apartment of Gabriella Ramiro*. This is Coffee Club Luisa, a daily klatch in honor of Mrs. Ramiro's daughter Luisa, who was killed last year by her common-law husband. The tragedy hit Mrs. Ramiro hard, plunging her into and a deep depression, and neighbors have been rallying to her support on a daily basis ever since.

The Club kicks off in earnest when Mrs. Ramiro's home health aide, Theresa Hernandez, returns to work. In fact, if Teresa is not there yet the Coffee Club cannot begin. "We like how she makes the coffee," the neighbors will say, and wait the few extra minutes until she arrives. Because of the cluster system, Partners in Care, the preferred vendor for home health aide staffing at the Visiting Nurse Service of New York, can split Mrs. Ramiro's limited home health aide hours so Theresa can help her get up and face the day first thing in the morning, can go to work for another client midday, then return to Mrs. Ramiro for another hour and a half, facilitating Coffee Club Luisa and making sure the soft-spoken grandmother does not sink into a twilight depression. When Theresa leaves for the evening, a couple close friends stay behind to keep Mrs. Ramiro's spirits uplifted.

Everyone looks out for everyone on the fifth floor. It seems as soon as Mrs. Ramiro gets teary-eyed with an overwhelming memory, a neighbor appears in the doorway with homemade soup, coffee cake, Café Bustelo, or a kind word and a warm smile. She, too, helps her neighbors and is proud of her role as floor "captain" -- an overseer who makes sure residents get the help they need, even calling for an ambulance if necessary. "All the time, helping," she says in Spanish.

Claudette calls these college dorm-like pockets of conviviality "contagions." The fifth-floor "contagion" is the building's standard-bearer, revolving around Mrs. Ramiro's apartment from morning to night. There is one blooming on the first floor, too, as well as the third floor, centered in the apartment of a couple that aide Maria Beralta cares for. In a recent conversation, in a mix of English and Spanish, Claudette and several aides described the third-floor's emerging "contagion." She has a sister on the hall... Yes, then the two friends across the way... Another one, three doors down, he comes over a lot... "These contagions are wonderful," says Claudette. "They're friends, they share needs, share cooking supplies. It's a real community. If someone's sad, another one will visit. Everyone comes together very spontaneously."

A Changing Workplace (Complete With Secret Santas)
As the 65-and-over population balloons from 40 million people in 2010 to 72 million in 2030, and people increasingly choose to age at home, we will experience an urgent need for home health aides in the coming years. The U.S. Department of Labor projects that over the next decade the country must add 1.3 million home health aides to the workforce (for an increase of 70 percent since 2010).

To encourage excellence and longevity on the job, we must find ways to support home health aides in this booming field. While my agency, Partners in Care, requires in-service training to add to the aides' professional toolbox, the cluster system provides an excellent day-to-day support system for the many challenges of the job. Whether in the halls or in the second floor office over lunch or coffee, aides at 99 Fort Washington regularly offer advice to one another on difficult days or with difficult clients and share expertise and experiences. Many aides have worked with their colleagues' clients before and can even offer specific tips: "Mrs. Romero prefers a bath to a shower. Mr. Desoto will sneak cake if you're not careful."

They have created a true workplace, something many of us take for granted, but in an industry marked by one-on-one assignments, something to be cherished. They keep a list of one another's birthdays so they can buy celebratory flowers, and they give gifts Secret Santa style over the holidays. "We're a team," Claudette says, and the five aides gathered for a morning meeting nod and smile.

*The names of all patients have been changed to protect their privacy.

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