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Home Health Services can play a central role in the ambulatory care of patients with both acute and chronic illness.  Certified Home health Agencies (CHHA) provide skilled nursing services in the home, using a RN as the coordinator of care.  The nurse performs clinical assessments and skilled intervention such as wound, ostomy and foley care.   The nurse is also able to provide clinical education and medication reconciliation.  Other key services include physical therapy, occupational therapy and speech language pathology.  The nurse may determine that a home health aide may be appropriate to assist with personal care and other ADLs.  Adjustments may be made to the patient’s medication regimen based upon the bloodwork or abnormal vital signs. 

Long Term Home Health Care may be appropriate for the chronically ill patient who has Medicaid insurance.  In some instance only a Home Attendant is necessary.  A nurse is available via pager to help determine what home care services are appropriate.  For questions about eligibility and insurance status contact the AIM social worker. 

AIM patients may be referred directly from clinic with a streamlined process of simply printing out a clinical note (with updated allergies, med list, problem list, PMD name, contact number), indicate clearly reason for visiting nurse services, attach a printed pt demographic and insurance pages.   These 3 documents should then be put in the 3 on-site VNS referral binders in both PIC rooms and VC 205. The binders will be checked by a representative from VNS on a daily basis. For referral to VNS hospice care call 212-290-3888 or fax 212-290-3933.

After the initial nursing visit is made, a certification Plan of Care (485 form) is generated and sent to your clinic mailbox. Please make it a habit to check your mailbox every time you attend clinic. Sign these forms as soon as you receive them. You can return signed form in the VNS mailbox below your mailboxes. Failure to return these forms in time may result in discontinuation of services for your patients!

Questions about eligibility and insurance status can also be referred to the AIM social work service.

The VNS web site can be found here. Their phone number is 1-888-VNS-1-call. The referral form  is no longer necessary for outpatient referral, but is posted here for inpatient use.



(Home Nursing Care page courtesy of Katherine Brown and Frank McMillan from VNS of New York )