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Colorado Visiting Nurse Association

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CAPABLE

Class

Health Care 

Beneficiaries

Aging, Elderly, Senior Citizens
Poor, Economically Disadvantaged, Indigent

Description

Colorado VNA is piloting a program in metro-Denver, the Johns Hopkins intervention CAPABLE, a patient-directed program that combines occupational therapy, nursing, and minor home modifications to improve older adults' functional goals.

The vast majority of older adults wish to age in their homes and communities. Aging-in-place means independence, access to friends and family, familiar routines, possessions and pets, and reduced risk of illness like airborne colds. However, in order to keep older adults in familiar surroundings, the surroundings must be able to support them and the seniors must be able to adequately function in them.

Launched as a research project in Baltimore by Sarah L. Szanton, PhD, ANP, FAAN, of the Johns Hopkins School of Nursing, and since expanded to three Michigan cities, CAPABLE is a five month, home-based intervention for low-income older adults with functional limitations. It entails ten, 60- to 90-minute home visits with an occupational therapist, a registered nurse, and a handyman who work together with elderly individuals to identify mobility and self-care issues in their homes and fix or
modify them.

Photos

Evidence of Program's Success

Innovation Lab

Class

Health Care 

Beneficiaries

Aging, Elderly, Senior Citizens
Poor, Economically Disadvantaged, Indigent

Description

Colorado VNA's Innovation Lab serves as an internal research and development program, allowing us to explore promising practices, foster creative collaborations with both health systems and community-based organizations, and creatively design or redesign systems, processes, and/or programs to ultimately achieve positive health impacts that are both sustainable and scalable.

Thanks to generous philanthropic support from diverse funders and individuals, Colorado VNA is currently exploring the following programs and services with in its Innovation Lab.

 CAPABLE (Community Aging in Place-Advancing Better Living for Elders)
CAPABLE is a home visitation program for older adults developed by Johns Hopkins University School of Nursing. Over the course of 10 visits, six with an occupational therapist and four with a nurse, clients identify self-care goals such as walking to the mailbox, doing laundry, or showering that they would like to address for improved functioning, and to live safely and independently at home. Based on the client's independence goals and their living situation, Habitat for Humanity of Metro Denver also plays a role by implementing minor home modifications such as safety bar installation and floor repair. Colorado VNA's CAPABLE program seeks to demonstrate that modest investments in short-term interventions can help older adults remain in their homes longer, improve health outcomes, and decrease medical costs.

 Telemedicine
In partnership with HealthONE at the Health Center of Aurora, Colorado VNA is implementing a telemedicine program to reduce hospital readmissions and improve the health status of approximately 125 high-risk individuals with heart failure, an exponentially growing and vulnerable segment of our state's older adults. The telemedicine program also aims to serve as a nurse extender by allowing virtual visits, which help ease barriers to care caused by the current, and growing, nurse workforce shortage despite a rapidly growing senior population with greater and greater health care needs. Colorado VNA ultimately strives to demonstrate the viability of utilizing innovative technologies to reduce the burden of disease for this specific chronic illness as well as better manage clinician resources, and expand telemedicine to global disease management in future years.

Photos

Evidence of Program's Success

Homemaking & Personal Care Services

Class

Human Services 

Beneficiaries

Aging/Elderly/Senior Citizens
Blind & Vision Impaired
Deaf & Hearing Impaired
Disabled, General or Disability unspecified
Poor/Economically Disadvantaged

Description

Colorado VNA assists elders and persons with disabilities with everyday challenges by providing light housework, meal planning, personal care/grooming, laundry, and travel to/from appointments. This critical service helps keep these individuals, especially low-income elders with chronic pain and worsening vision, out of skilled living facilities. These services are provided as part of a physician's care plan and free-of-charge to vulnerable elders who demonstrate need thanks to generous donations and grants.

Photos

Evidence of Program's Success

In its most recent client satisfaction survey, 93% of individuals who responded reported that Colorado VNA's homemaker services are helping them to remain in their homes.

Anecdotally, we know from survey comments that the majority of elders are pleased with their care, and thus, we presume, have an improved emotional state of health, too. Typical comments to the question "If you did not receive homemaker or respite care services, what would you do?" include:
-be very unhappy;
-live in a dirty home;
-do without and suffer; and
-endure more pain doing the things my caretaker does for me.

HOPE

Class

Human Services 

Beneficiaries

Adults
Disabled, General or Disability unspecified
Homeless
People With AIDS

Description

HOPE - Homeless Outreach Pharmaceuticals Education
Colorado VNA provides supportive services and medical management to assist homeless persons living with HIV/AIDS. The program operates as a day program that provides medical assessment, mental health counseling, support groups, education, HIV specific nutrition, personal care training, and resource referrals including links to transitional /permanent housing options. Program staff get to know clients and develop an individualized care plan that becomes the basis for frequent check-ins. The program is funded by a federal HOPWA (Housing Opportunities for Persons With Aids) grant administered by the City and County of Denver's Office of Economic Development.

Photos

Evidence of Program's Success

The HOPE/HOPWA program has increased the range of housing options and related services for persons living with HIV/AIDS by providing community resource information for housing, assisting with housing applications and transitional and ongoing support for persons living in housing situations. By assisting with resources and resource referral Colorado VNA has increased the number of homeless persons moving into permanent housing, thereby decreasing chronic homelessness.

The extensive education and networking done by the program team has also improved the understanding of health care providers and the public of the special needs of the homeless and persons living with HIV/AIDS

Home Care

Class

Health Care 

Beneficiaries

Adults
Aging/Elderly/Senior Citizens
General Public
Military/Veterans
Poor/Economically Disadvantaged/Indigent

Description

The Home Care division provides nursing (post hospitalization care, wound care, intravenous (IV) therapy, psychiatric nursing), rehabilitation therapies (physical, occupational, speech), medical social work (psychosocial support, connections to community resources), and in-home services, or paraprofessional assistance (personal care, homemaking) to support people recovering from illness or injury.

Nearly half of the seniors that receive in-home services are low-income and pay nothing for this program. The majority of philanthropic dollars raised annually are allocated to this critical community service.

Photos

Evidence of Program's Success

Colorado VNA uses Strategic Healthcare Partners (SHP) to manage clinical outcomes, financial performance, patient satisfaction, and regulatory compliance in real time. SHP is web-based and tracks scores for Colorado VNA services (e.g., ambulation, dyspnea, wound care, etc.) that are posted on Centers for Medicare and Medicaid Services' (CMS) Home Health Compare report.

The most recent Home Health Compare report indicates that less than 15% of Colorado VNA patients are readmitted to the hospital, putting VNA in the top 10% nationally. (Hospital readmission, especially for Medicare patients, is an indicator of poor care, so Colorado VNA strives to remain below the national average

Hospice & Palliative Care

Class

Health Care 

Beneficiaries

Adults
Aging/Elderly/Senior Citizens
Military/Veterans
Poor/Economically Disadvantaged/Indigent

Description

VNA Hospice & Palliative Care provides a continuum of end-of-life care for clients and their families including advanced chronic care management for those with life-limiting conditions as well as palliative care and pain management for those terminally ill who are estimated to have 6 months or less to live. The hospice team's comprehensive approach focuses on the physical, psychosocial and spiritual needs of each client.

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Evidence of Program's Success

Evidence of Program Success is documented via the numerous thank you notes and positive survey responses received from family members. Additionally, Colorado VNA is pleased to report that its hospice services are equal to or above state and national averages in 10 of 11 domains including Providing Emotional Support, Information Continuity, and Overall Rating of Hospice.

Senior Wellness and Medical Foot Care

Class

Health Care 

Beneficiaries

Adults
Aging/Elderly/Senior Citizens
General Public
Poor/Economically Disadvantaged/Indigent

Description

A Senior Wellness and Medical Foot Care visit is a 30-minute session with a nurse that includes a general health assessment, medication review, foot care (neuropathy tests and toenail trimming), and monitoring of chronic diseases such as diabetes. A visit also entails individual health "coaching" which includes reminders about the importance of taking medications as prescribed, as well as physician referrals if any readings are "out of normal" range. Colorado VNA partners with community-based organizations, senior centers, churches and other companies to host community-based foot care clinics for older adults to attend. Over 150 clinics take place monthly through the Front Range.

In addition to medical foot care, Colorado VNA's Wellness Services also include flu immunization clinics and corporate wellness services whereby we partner with businesses to promote healthy lifestyles for employees in and out of the office. Options include immunizations, health risks assessments, biometric screenings, and labs.

Photos

Evidence of Program's Success

Colorado VNA is in the process of refining its patient satisfaction survey for Wellness Services. Anecdotal evidence, such as stories from our nurses and patients, also demonstrate success. By way of example:

Becky is a long-time Colorado VNA Senior Wellness Clinic patient. A couple of years ago, Becky began to experience prolonged fatigue and a rapid pulse. Nurse Debbie noticed other symptoms as well including poor coloring and a sense that "Becky just wasn't herself." Becky had relayed these symptoms to her physician at Nurse Debbie's urging, but they were not deemed urgent enough to warrant a check-up. After six weeks and continued prodding from Nurse Debbie, Becky made her way to a hospital where she was diagnosed with blood clots in her lungs. Nurse Debbie's diligence allayed a potentially dangerous situation. Becky is now on medication and responding well to treatment. And, she has an expert nurse watching over her.

A diabetic client came to a clinic last year with a large, open wound on the bottom of her foot that she was completely unaware of due to peripheral neuropathy. The client was sent to see her PCP for wound care and a possible future amputation was avoided due to this nurse's prompt attention to the client's issue. The wound healed completely and the client was extremely grateful!

One RN detected an irregular heartbeat in a patient. The patient followed up with his PCP, who ended up needing surgery else he may have had a stroke.

Another nurse found a mole on a patient's leg and urged the patient to request a biopsy. The mole ended up being malignant cancer and was subsequently treated.

Colorado VNA nurses also occasionally care for homeless seniors at Wellness Clinics, some of whom are then escorted to emergency rooms for immediate treatment of conditions such as diabetes and high blood pressure.

Key aspects of this profile information have been reviewed by Community First Foundation staff. Each organization is exclusively responsible for the content that appears on the profile page. Community First Foundation offers general guidance as to the purpose of each area but does not require or encourage charities to include anything in particular in each section.