Our Home Care Technologies Help Us See, Know, and Provide More

We are in the middle of a home health care revolution, one shaped by the rising numbers of people living with multiple chronic illnesses and accelerated by the COVID-19 pandemic. Following the harrowing surges in 2020 and continuing into 2021, it is clearer than ever that, moving forward, New Yorkers want to age in place, in their own homes, no matter their state of health. And health plans have begun focusing their efforts on making that happen, safely and in a cost-effective manner.

The Visiting Nurse Service of New York, where I work, has been taking care of vulnerable people in their homes for 128 years. We understand the home setting and how a coordinated, team-based approach can help people across the spectrum of illness understands and live better with the physical and behavioral health challenges they face. We increasingly care for those with multiple chronic illnesses, including serious conditions that limit mobility and other daily activities. They will not “recover” from their conditions, but with the proper care and care coordination, as well as patient/member education, coaching and empowerment, they can live many fulfilling years or decades. Our wrap-around care addresses social determinants of health as well, which have a profound impact on how people live.

At VNSNY and at care organizations across the country, technology has become a vital tool for amplifying access and the impact of home care, both on an individual basis and at the population level. I’ve written before on the vital role telemedicine can play in keeping vulnerable individuals connected to care in the safety of their homes. The use of remote and urgent care in the home has been accelerated by the pandemic, and I believe that these advancements, thankfully, are here to stay.

On the population level, VNSNY has been pioneering exciting technologies that help us improve care and drive better outcomes by allowing us to see patterns in our care, predict risk, and guide interventions based on data.Leveraging machine learning, we deploy predictive algorithms to inform our plans of care. Using data that begins with a comprehensive assessment at the first visit, these algorithms can predict whether someone is at low, rising, or high risk of hospitalization. Based on this information, we can tailor our treatments and interventions to help them stay safe at home and out of the hospital. 

We also use predictive algorithms to determine whether someone we are caring for might qualify for and benefit from other programs such as palliative care or hospice services.

In addition, we’re breaking down siloes, so all the members across our interdisciplinary teams have the insights they need to coordinate and integrate care. Strategically designed dashboards enable us to see the big picture, in real time, and adjust our interventions to drive the best outcomes. In creating dashboards, we are guided by the image of the instrument panel when you’re at the wheel of your car—a harmonized, single point of entry. By seeing what the full team is doing at all times, across the spectrum of services, we can see what’s working and what isn’t. We can then dial up or dial down particular kinds of care to make sure we’re delivering the right care at the right time to the right person.

We have also developed technology that gives us a window into hospitalization and emergent care data, so we can see—again, in real time—whether a health plan member we are caring for has been admitted to or discharged from the hospital or seen in the emergency room. As we work to reduce preventable rehospitalizations, this is a crucial piece of information for our care management teams, helping them to provide the appropriate interventions for an effective transition home and avoid further hospitalizations.

Technology does not, and should not, replace the compassionate, humane care we provide to people in their homes. Rather, it enhances this care – it allows us to do a better job of delivering services, both by keeping individuals connected to care and by giving us deeper insights into evidence-based, real-time approaches that will improve outcomes—individual by individual—for entire populations in our care.