Population Health and Clinical Support Services

COVID-19 highlighted the home as the forefront of health care—and health care innovation. Social distancing meant that everyone, especially the elderly and those with underlying conditions, were isolated in their homes. But they still desperately needed connection to care, health information, and expert oversight. And health care providers needed to make sure they could deliver the right care at the right time in the right place, which was, increasingly, the home.

The Visiting Nurse Service of New York, where I work, accelerated the development and deployment of personal technologies to drive telemedicine in the home and innovations in data usage and machine learning to help us better integrate care and drive outcomes.

While COVID-19 has magnified the urgency and extended the reach of home care innovations, VNSNY has been advancing novel care delivery models and technologies in the home for nearly 130 years. Our innovation at the forefront of care and crisis dates back to our earliest days, when the last global pandemic devastated, among millions of others, New York City’s vulnerable immigrants and the working poor packed into tenements and without proper access to health care. Lillian Wald, VNSNY’s founder and the nation’s first public health nurse, led a team that created daily records and used that data to help New York City coordinate its response to the 1918 Spanish flu pandemic.

During the AIDS crisis beginning in the 1980s, VNSNY developed new models of care to bring patients the compassionate care they needed amid an infectious disease whose spread was not widely understood. These included palliative measures and, later, pioneering approaches to treat, track and care for HIV-positive women who transmitted the illness to their babies during childbirth. When Superstorm Sandy devastated the city in 2012, VNSNY nurses knocked on countless doors and mobilized deep into the community, advancing preparedness measures for an unpredictable climate future.

When COVID hit in 2020, VNSNY was well positioned to accelerate the implementation of home health technology. Our care management organization had been building a telemedicine infrastructure for people living at home with multiple chronic conditions—a fast-growing population of Americans whom VNSNY is committed to serving. Addressing home care at the population level, VNSNY has developed technology that helps us see patterns in our care, predict risk, and guide intervention based on data. We break down siloes, so members across an interdisciplinary team 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

Leveraging machine learning, we deploy predictive algorithms to inform and guide our plan of care based on evidence. Using data that begins with a comprehensive assessment at the first visit, the algorithms can predict whether someone is at low, rising, or high risk of hospitalization. By evaluating their risk, 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 hospice services or palliative care.

Strategically designed dashboards enable us to see the big picture, in real-time, and adjust our interventions to drive the best outcomes. We model these dashboards on the panel at the front of a car, a harmonized, single point of entry for all necessary information. By seeing what the team is doing at all times, across the spectrum of services, we can see what’s working and what isn’t, and can dial up or dial down particular kinds of care to make sure we are delivering the right care at the right time to the right person.

We have also launched technology that gives us a window into hospitalization data, so we can see—in real-time—whether a health plan member we are caring for has visited the emergency department or been admitted to or discharged from the hospital. As we work to reduce preventable rehospitalization, this is a crucial piece of information for our care management teams, so they can provide the appropriate interventions for the transition home and to avoid further hospitalizations.

When crisis hits, it usually hits the vulnerable disproportionately hard. Progress in home health care’s delivery of telemedicine, data collection and usage, and machine learning positions us to better reach and care for those who are at risk—and isolated in their homes—as the world faces increasing external threats from climate change, overburdened infrastructure, and future infectious disease epidemics. After all, health care innovations are only as good as their ability to solve timely challenges and build a path to a better future.