Health Home” is not a place… it is a group of health care and service providers working together to make sure you get the care and services you need to stay healthy.

Call 607-883-2565 to make a referral or use the application form.

Advanced illness management, or AIM, will help patients with advanced chronic illness manage their health in ways that closely align with the patient’s goals. Visiting Nurse Service chose to develop the AIM program in 2019 because the population is aging, we found that payers want to keep patients out of the hospital, community partners are asking for help in managing patients with long term chronic diseases and patients and their loved ones are hearing about specialized community-based care and want to receive it. 

Serious illness impacts the quality of life and the ability to function impacting both the patients and their loved ones. Visiting Nurse Service AIM multidisciplinary team will partner with patients, their loved ones, primary physicians and other healthcare providers to offer a range of assistance including relief of pain and other distressing symptoms, improved understanding of what to expect from their illness(es), medication management, emotional support for patients and caregivers, assistance with goals of care and planning for future needs.

AIM is a palliative care program that is appropriate for anyone, at any age and any stage of serious illness.  Curative treatment can also be received at the same time.   The benefits of a palliative care program like AIM is to improve patient/family understanding of what to expect, decrease the number of crisis, have fewer 911 calls, have fewer emergency department visits, fewer hospitalizations and relief from stress for the illness. 

Visiting Nurse Service understands that with serious illness, all patients should have access to quality, comprehensive care.  In order to reach his goal, all VNS staff have been trained in pain and symptom management, communication about achievable goals and care coordination across all settings.  We welcome the opportunity to help fill the current gap in access to community-based palliative care.

Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. Visiting Nurse Service embraces this concept and has trained all of our staff in the principles of motivational interviewing.  The goal of motivational interviewing is to work in partnership with our patients so that their goals and ideas are respected and become part of the care plan developed for each of them.  It is patient centered care!

Principles of motivational interviewing include expressing empathy, rolling with resistance, developing discrepancy and supporting self-efficacy.  There is a true “spirit “ of motivational interviewing which includes collaboration, evocation and autonomy.  Skills that the staff use include open ended questions, affirmations, listening reflectively and helping patients understand their ambivalence by summarizing back to them some of their words so that they can hear where they may be stuck. 

Applying all of these principles, the spirit of MI and using the skills helps us lead patients to change that is needed to better control their disease state, keep them out of the hospital or nursing home and help them stabilize their condition so that they are able to have a higher quality of life while being able to live at home.  Home is where people want to be and be maintained there as long as possible!

Addressing health literacy means improving the way we communicate with patients and help people improve their own skills and knowledge.  Nearly 9 of 10 adults will struggle with health information. Highest risk are most vulnerable including the elderly.  Most health care information is written at the 12th grade level – most individuals prefer material at an 8th grade level. People who cannot understand will fail to correctly follow instructions. People with limited literacy have higher rates of hospitalization.

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Researchers and practitioners, as well as VNS, are recognizing the importance of moving beyond an individual focus, and of considering health literacy as an interaction between the demands of health systems and the skills of individuals.

Health Literacy is an individual’s ability to obtain, process, and understand and act upon health information AND a health professional’s capacity to communicate clearly, educate about health and empower their consumers AND a healthcare system’s capacity to balance the skills of individuals and the complex demands of their organization.

Visiting Nurse Service understands the role our organization plays in health literacy and we are committed to being a health literate organization which means all of our staff including our Board of Directors is committed to support these concepts.