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Bringing Public Health Home: A Response to 'What Can Mississippi Learn From Iran?'

This is where home- and community-based health care play a vital role, bringing comprehensive care to people where and when they need it, keeping costs down by emphasizing wellness, self-management and continuity of care.
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America's public discourse today often centers on how to best provide sustainable, cost-effective health care for all. Our fragmented health care system costs us dearly, both in dollars spent and in lives unfulfilled. As the president and CEO of the country's largest not-for-profit home health care organization, the Visiting Nurse Service of New York, I believe our mission every day is to work at reducing these costs by putting the public back into "public health."

I recently read with interest the New York Times Sunday Magazine's cover story, "What Can Mississippi Learn From Iran?" This thought-provoking article puts a compelling human face on the extraordinary challenges of ensuring that the most vulnerable among us -- from infancy to old age and regardless of circumstance -- receive the care they need to remain as safe, healthy and independent as possible at home and in the community. As Americans live longer and the prevalence of chronic diseases rises, the challenges are so great that they demand bold new thinking and broad-based partnerships. Health care providers must work together with schools, religious groups, senior centers and other community-based organizations to make sure no one falls through the cracks.

While it was encouraging to read about the solutions for rural Mississippians who suffer under the multi-layered burdens of poverty, chronic disease and lack of access to health services, I would suggest that the dedicated teams in Mississippi did not need to travel as far as Iran for innovative, successful models. They could have looked much closer to home.

Across the United States, more than 1,500 not-for-profit home health care agencies weave an essential safety net for millions of individuals and families without access to primary and preventative services. At our agency alone, highly-trained caregivers working on the front lines serve some 31,000 patients a day, visiting them in fourth-floor walk-ups on the Lower East Side, homes of new teenage mothers in the South Bronx, senior centers in Queens, and throughout the city and surrounding suburbs.

In the Times piece, a hospital's nursing director asked of the Mississippi model of holistic, integrated care: "What you are describing is home health, isn't it?" I was taken aback that the article went on to suggest that no, it is not -- that home health care is essentially limited to nurses providing episodic clinical care in patients' homes.

Nothing could be farther from the truth.

In-home clinical care by visiting nurses is a central piece of home- and community-based health, but it is far from the whole picture. Successful home health care involves integrated teams working together -- nursing, coaching, advocating, listening, educating, connecting, transforming -- always focused on the needs and goals of each patient. These teams include skilled nurses, home health aides, behavioral health experts, rehabilitation therapists, social workers, bereavement counselors, nutritionists and physicians.

Defining Home Health Care

If the on-the-ground experts featured in the New York Times article do not recognize what they are developing as home health care, then those of us who practice, shape and believe in it must do a better job of education. We must define what home- and community-based health care is -- who needs it, who does it, how it works, who benefits, how to access it, and how it saves money and translates to better health outcomes.

When nurse Claudette Bourque waits by the fifth-floor elevator of a New York City public housing project to be there when her patient, 78-year-old Bienvenida Torres, first learns the devastating news that her daughter has been murdered, that is home health care. When Ms. Bourque drives across the Bronx on a Sunday to join Mrs. Torres in releasing 51 balloons in honor of her daughter that, too, is home health care. A member of our Medicaid Managed Long Term Care health plan VNSNY CHOICE, Mrs. Torres receives care from a team that includes Ms. Bourque, several home health aides who are "like members of the family," and a social worker and behavioral health therapist who help her battle depression. This team is the safety net that helps Mrs. Torres heal and avoid the isolation that, for many older Americans, precipitates a downward spiral. And in this innovative MLTC plan, this essential set of home health care services does not require Mrs. Torres to reach into her own pocket for payment.

When an at-risk teenage mother learns concrete parenting skills like diapering and feeding as well as intangibles such as self-esteem and patience -- and says with confidence, "My daughter doesn't have to worry that mommy's having a bad day and, oh, I have to stay away from her!"--that is home health care. Our Nurse-Family Partnership is a national, evidence-based program that consistently results in improved prenatal health, fewer childhood injuries, fewer subsequent pregnancies, increased maternal employment and improved school readiness, transforming lives into the next generation. Early interventions and deep partnerships -- like this one between a young mother and a nurse who visits her at home from pregnancy through the child's second birthday -- need to be available everywhere.

When community-based nurses in Queens spring into action to gather medicine, draw insulin and package several days' worth of supplies for seniors evacuated during Hurricane Irene, that is home health care. So, too, is the education and empowerment taking place at the Green Avenue Houses in Bedford-Stuyvesant, where nurses, social workers and home health aids work on site to help seniors understand the lifestyle choices that lead to good cardiac health -- and thus keep themselves healthier.

When ethnically-diverse caregivers literally speak the language of their community -- whether that means a Russian social worker connecting recent immigrants in Queens to much-needed resources, a culturally sensitive Chinese-speaking bereavement counselor helping Chinatown residents cope with loss, a Spanish-speaking nurse educating patients in the largely Dominican neighborhood of Washington Heights, or a home health aide who speaks Yoruba working in a Bronx neighborhood of new African immigrants -- that, too, is home health care.

While polar opposites in many ways, rural Mississippi and parts of New York City have much in common, including widespread poverty, epidemic rates of obesity, a skyrocketing chronic disease burden and significant barriers to accessing care. This is where home- and community-based health care play a vital role, bringing comprehensive care to people where and when they need it, keeping costs down by emphasizing wellness, self-management and continuity of care.

The Times piece closed with an oxygen-dependent woman unable to afford life-changing mold removal in her home. That is not where the story should end. Successful community-based health care must press into service all manner of partnerships and resources to tear down barriers to access and improve the health and well-being of our communities' most vulnerable.

All of us need to work together to make this happen. We all need to take on the spirit of Nerys Rosario-Rivera, a social worker in the Bronx who is known in the neighborhood for her determination to find solutions and her refusal to take no for an answer. When a new patient, Carmen Perez who, like Vonda Wells in the Times story, suffers from severe asthma, could not sleep because her bedroom was riddled with mold, Nerys spent three weeks and more than 40 hours on the phone navigating city agencies to finally obtain an inspection for Ms. Perez's apartment, at no cost to her.

Helping Carmen Perez breathe easier -- that is home health care in action.

For Carmen Perez, it was a solution. For the rest of us, it is just a start.

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