A Shining Example of Teams Working Together for Nursing Home Hospice Patients

Teams Featured:  Business Development, Personal Care and Hospice Care

For VNS Health home health aide Delores Yearwood Pile, her job providing care to VNS Health Hospice patients at a large skilled nursing facility in the Bronx keeps her on her toes—literally.

“I might begin my shift by giving one patient a bath and then dressing her in a set of fresh clothes and feeding her,” she says. “Then I’ll walk a short distance and do the same with another patient. An hour later, I’m on to a third patient. And in between these visits, I’ll circle back to check on the others. Every minute I’m there, I’m providing important help to someone—plus, it gives variety to my day!”

When Delores’s shift is done, another VNS Health aide will follow a similar routine with the same patients. This rotating care is a hallmark of VNS Health’s new “Cluster Care” hospice model. Designed for nursing homes and other group settings, the model calls for assigning a number of hospice-trained home health aides (HHAs) to the facility on a permanent basis. These HHAs then circulate among multiple hospice patients, serving as a key hospice team member along with VNS Health’s hospice nurses, social workers and spiritual counselors, and our dedicated hospice volunteers.

Cluster Care: A Shining Example of One VNS Health – and VNS Health’s Mission

The Cluster Care model is a shining example of different parts of the organization working as one VNS Health to provide the best possible care—in this case, through the collaboration of our Business Development, Personal Care and Hospice Care teams.

Business Development (BD) got the ball rolling by identifying the Bronx nursing facility’s need to find a way of caring for multiple hospice patients in a coordinated fashion. Building on their existing relationship with the facility’s management, the BD team then worked as the liaison to help get the program up and running.

VNS Health Personal Care provided the skilled, hospice-trained HHAs and set up a workable structure for delivering care. “This new model draws on all the great skills of our HHAs—not only their dedication to those they care for, but also their ability to work with their fellow HHAs in creative, flexible ways,” notes Ivette Adorno, Unit Manager, Personal Care. At the same time, VNS Health Hospice Care tailored their patients’ plans of care to conform with the Cluster Care model.

“It’s been a great instance of teamwork, with everyone breaking down siloes to bring all of our talents to bear,” says Roisin Rogers, Director of Strategic Account Development. The collaboration between Personal Care’s specialized hospice HHAs and other VNS Health Hospice team members is an essential part of the Cluster Care model. VNS Health Hospice clinicians make it a point to check in with the HHAs as they visit each hospice patient in the nursing facility, and the HHAs will also alert the rest of the hospice team if the patient’s condition changes. 

Cluster Care Also Means Close Teamwork Among the Nursing Facility’s HHAs

The unique nature of the Cluster Care model also requires close teamwork among the facility’s HHAs, since the sharing of patients puts a premium on communication and smooth handoffs. This need actually led to the creation of a new Hospice team position: Lead Hospice HHA for the nursing facility, a role held by Michelle Ademokun. “The Lead HHA keeps track of all the VNS Health Hospice patients in the nursing home and where they’re located,” says Natalie Cheltenham-Festa, Associate Vice President, VNS Health Hospice Care (pictured above). “The Lead HHA is responsible for setting each HHA’s patient care schedule in coordination with the nursing home manager.”

A Win for Everyone

The teamwork-based model is a win for everyone: Hospice patients get better care, the VNS Health team members are in a better position to support and reinforce each other’s efforts, and the nursing home is better able to offer outstanding end-of-life services to their patients and their families. “Since launching our first Cluster Care team earlier this year in the Bronx, we’ve gotten extremely good feedback from the nursing facility,” notes Natalie. “We look forward to employing this model with other nursing home partners in the coming months.”

To read more “Now That’s Teamwork” articles on Frontline, click here.