(CHF). These diagnoses occur with an average of four other conditions; some common co-occurring diagnoses are CHF and chronic obstructive pulmonary disease (COPD); CHF and diabetes; and hypertension and dementia. On average, patients take eight different medications. About 9 percent have cognitive impairments, and 16 percent have a history of diagnosed depression or self-reported symptoms of depression—a figure that is likely an underestimate of the true proportion of cases suffering from depression. They usually have impairments in five to six ADLs (activities of daily living). About 50 to 75 percent of patients are from minority groups, and at least 36 different languages are spoken across VNSNY’s patient population.
The nurses who provide care through the VNSNY “have to do it all,” said Raphael. “They are the admissions office. They have to do the financial eligibility. We say, ‘When we walk into a home, we walk into a life.’ Our second major reason for worker’s compensation claims among our nurses is dog bites.2 You never know what you are going to face when you walk into someone’s home.”
The role of the VNSNY nurse varies depending on the setting and the needs of the patients. In congregate care, the role of the onsite nurse is threefold:
To conduct health promotion and education activities for residents, families, and building staff.
To provide case management for residents who need ongoing support for chronic conditions and to provide linkages to community resources.
To screen, assess, and link residents to home health care as needed.
For home care patients, the coordination of interdisciplinary care is a critical function of visiting nurses. They help patients recover and regain functioning, learn to manage their own conditions, avoid exacerbations in chronic conditions, and build up strength and endurance. This can encompass a wide range of nursing roles. Nurses may assess needs, the home environment, and financial coverage; develop and implement a plan of care; facilitate communication between and among providers and patients; document progress; manage medications; monitor for declines;