In 2009, approximately 12,658 patients were served from our Central/Manhattan Office on Water Street and our Bronx/Queens Borough office on the campus of Elmhurst Hospital. These 12,658 patients resulted in approximately 230,058 visits; 38% of these visits were for Nursing, 57% Home Health Aide, and 5% Therapies or Social Work; 63% of patients were low-income (Medicaid), and 91% were ethnic minorities (Hispanic 37.5%, African-American 20.2%, Asian 4.4%). Our patients’ primary diagnoses are related to chronic diseases commonly associated with poverty and urban health concerns, such as Diabetes, HIV, Hypertension, Asthma, Chronic Airway Obstruction, and Congestive Heart Failure.
While most patients are referred to us through their discharge plans from City hospitals, we receive many referrals from community-based physicians.

Our mission is “to provide quality, compassionate, accessible and affordable home health services to residents of New York City.” Our vision is “to serve as a pre-eminent building block in the continuum of New York City’s health services”. As a vital, evolving entity, we constantly pursue opportunities to develop new and innovative ways to deliver the finest community-based services available to the residents of New York. Through performance improvement efforts, we aim to continuously enhance the services we provide and the resulting outcomes.

HHC Health and Home care plays a vital role in meeting the City’s health care needs, as we serve a population that is primarily low-income. In keeping with our mission, many of our patients are uninsured. Through our team of nurses, social workers, and rehabilitation therapists, we provide the patient and family with comprehensive home health care and case management. To serve their medical, emotional, and supportive needs, the team develops a comprehensive plan of care, which, in addition to home health nursing, may also provide physical, occupational and/or speech therapy, social work, and home health aide services. We also refer our patients for specialized services when appropriate. We provide home health services to two main types of patients: 1) those discharged from HHC hospitals after an acute episode, and 2) those referred to us from the community, both of which need skilled nursing and other services in their home. In addition to acutely ill patients, some have chronic conditions as described above, and require specialized care through referral to one of the following programs, which are all supported by 24-hour on-call services.

• Long-Term Home Health Care Program or “Nursing Home Without Walls” program provides nursing, therapeutic, and daily living services to patients whom we expect will need care in their own home for an extended period. The goal is to maintain and support health and independent living skills as an alternative to placement in a nursing home or other long term care facility. This program is available to eligible patients residing in the Bronx and Manhattan.
• Maternal Child Health Program offers prenatal and postpartum care to mothers and their children with special needs, including home health nursing and education to improve the expectant mother’s health, prevent/treat postpartum medical complications, educate new parents in parenting and child-care skills, and assist in adjustment to the new family structure. Through a team approach, we monitor and treat long-term infant health problems and support the mother and family on multiple levels.
• Hi-Tech Program administers parenteral and enteral therapies to patients in the comfort of their homes, as a safe and effective alternative to hospitalization or other institutionalization. Therapies include antibiotic, hydration, nutrition, pain management, and others as required. A highly trained team assesses, treats, and monitors the patient, while supporting and educating the family about the patient’s care. Case management, supplies, and equipment are provided as needed.
• Behavioral Health Program helps individuals with psychiatric illness manage their care in the least restrictive environment – their own home - to reduce symptoms and encourage more independent functioning. In conjunction with the families and health care providers, the patient may be served through: psychiatric nursing and social work; physical, occupational, speech, and respiratory therapy; nutrition; home health aides, and/or medical equipment. The program is designed to reduce hospital length of stay and frequency of re-hospitalization, increase adherence to treatment regimes, provide self care education, and help the patient reach maximal health, safety, and independence.
• HIV/AIDS Program assists uninsured or underinsured patients living with HIV or AIDS to maintain or improve the quality of their lives. Through an individualized plan of care and the full range of services described above, patients are encouraged to continue treatment, learn about and live with the wide range of HIV-related symptoms, manage side effects of treatment, and cope with stresses related to living with the illness. The program is designed to reduce hospital length of stay and frequency of re-hospitalization, provide an alternative level of care for patients who might otherwise require nursing home placement, increase adherence to difficult treatment regimes, and assist individuals with HIV/AIDS reach maximal health, safety, and independence.

In addition, other programs improve patient health by supporting direct services and staff education.

• The “House Calls” Telehealth program is a program available to H&HC patients which combines secure web-based monitoring with traditional nursing visits to help patients with chronic health conditions develop effective self-care behaviors. We are already finding that our Telehealth patients are showing marked improvement in their health, along with a reduction in emergency room visits and hospitalizations.
• The Home Health Nurse Intern program trains registered nurses without prior home care experience to become home health nurses in 7 months, with personalized Preceptor instruction and supervision. It is fully supported by a federal grant that began in 2004.  Click here to access the Final Report submitted to HRSA (grant funder) about this program. 
  Final Report  
• The Staff Development program provides education in clinical and workplace skills, and periodic retraining on mandated topics, taught in classes in and one-to-one field mentoring sessions. We are working to obtain funding for a distance learning component that would allow staff to access educational resources from any location.
• The Patient Safety and Performance Improvement programs support superior quality service by identifying opportunities for system and program enhancements, developing plans to improve, and monitoring the plans as well as the outcomes. Results are measured and reported and plans are changed as appropriate.

All of the above services are coordinated with one purpose in mind: “to provide quality, compassionate, accessible and affordable home health services to residents of New York City.”