Two Teams, One Shared Goal: Help a Veteran Stay Safe and Stable at Home

When Lawrence*, an 88-year-old Marine vet, came home from the hospital this past winter as a VNS Health Home Care patient, there was a lot to manage: He was recovering from a congestive heart failure (CHF) attack, and needed significant support to keep him safe and stable in the downtown Manhattan apartment he shared with his wife. To make matters even more challenging, he had lost his hearing aids during his recent hospitalization, leaving his hearing badly impaired—a fact that was causing him great distress.

Fortunately, Lawrence had not one but two excellent VNS Health teams working together to care for him: his Home Care team and his Veterans Services team.

When Kristen Wong, the Home Care nurse who admitted him, learned Lawrence was a Marine veteran, she immediately linked him with the Veterans team, where Lawrence and his family were paired with Victor Interiano, Veterans Outreach Liaison, and Anna Altunyan, Veterans Services Specialist, who specializes in disability benefits applications.

One of the first things Anna did was address Lawrence’s missing hearing aids. When she heard from his family that Lawrence’s work on a military airfield might have been the cause of his hearing loss, she explained that this could entitle him to free replacement hearing aids from the VA. She went on to help the family complete the paperwork needed to submit a hearing loss disability claim.

In addition, Anna began exploring other benefits he might be entitled to, including VA Home-Based Primary Care as well as transportation assistance to and from doctor’s appointments.

‘Thank you for recognizing him’

Besides linking veterans to their benefits, the Veterans Services team provides support in other important ways. On a Thursday afternoon home visit in early February, Victor, Anna and Teresa Lin, Vice President of Cultural Market Development, held a recognition ceremony in Lawrence’s home, honoring his military service. The team presented him with a red-white-and-blue blanket handmade by the Daughters of Veterans on Staten Island, and a challenge coin—a military tradition signifying shared service.

“I feel so proud to be American right now,” Lawrence wife told the group. “Thank you for recognizing him.”

As a veteran himself, Victor brings a special understanding and compassion to his work with veteran patients. “They raised their right hand and swore an oath to serve,” he notes. “In our home visits, they’re able talk with somebody else who knows what that experience was like—sometimes for the first time in a long time. Our hearing their stories and acknowledging their service is a way of saying, ‘We appreciate you.’”

Educating, Engaging and Empowering

While the Veterans Services team was opening doors to additional benefits and honoring Lawrence’s service, his clinical team—which included Alex Zhao, RN, Coordinator of Care, as well as a physical therapist, occupational therapist and social worker—was focused on stabilizing Lawrence’s health and equipping him and his family to manage his condition.

Over four weekly visits, Alex educated Lawrence and his family on the foundations of CHF management, including diet, monitoring of fluid intake and output, medication management, and daily weight tracking. On his first two visits, Alex weighed Lawrence and logged the information. The third visit brought a turning point. Lawrence was doing the weighing and recording himself—even taking off his loafers, so the number would be accurate. “That’s when I knew he really understands what we want to do,” says Alex.

On his final visit, Alex met Lawrence not in his chair but at the elevator bank downstairs. Lawrence was coming back from the pharmacy, medications in hand, and moved with energy and purpose. “Instead of visiting the patient,” Alex recounts, “it was almost as if we were meeting to go up to his home together.” The patient who had been sitting quietly in his chair weeks earlier was now back to himself, his family, and his life.

*The patient’s name has been changed for privacy.