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What is the Living at Home/Block Nurse Program?
Who governs the Program?
What services are coordinated by the Living at Home/Block Nurse Program?
How does the Program work?
How are the nursing services paid for?
What are the Program's principal benefits?
What are the outcomes of this Program?
Can the Program be replicated in other communities?
What awards has the Program received?
How do Program expansion and financing work?
How do I get started building a Program in my community?
What is the Living at Home/Block Nurse Program?
It is a community Program that draws on the professional and volunteer services of local residents to provide nursing, companionship and chore services to their elderly neighbors who might otherwise be institutionalized.
The Living at Home/Block Nurse Program (LAH/BNP) was formed in 1991 to demonstrate the viability of an integrated, neighborhood-based senior care model to assist older persons wishing to remain in their homes. As can be seen in the name, this model represents the joining of two previously established programs that successfully implemented neighborhood models of care.
Two Successful Programs
The Block Nurse Program was founded in 1981 in the St. Anthony Park community in St. Paul. In 1985 expansion to other neighborhoods began, and it soon included the Highland Park and North End/South Como neighborhoods in St. Paul, Prospect Park neighborhood in Minneapolis and the small town of Atwater in west central Minnesota. The Program provided an alternative to expensive nursing home care by using neighborhood nurses, home health aides and local volunteers to serve frail elderly participants in their homes.
In 1986, the Ford Foundation and Harvard University presented the Program with the prestigious Innovations in Local Government Award as an outstanding grassroots management model. In the same year St. Paul was selected to be one of 20 sites for the National Living At Home Demonstration, aimed at helping seniors to avoid premature institutionalization. The Living At Home Program, designed to implement a community-based senior care model, operated for three years in the West Seventh and Macalester/Groveland neighborhoods in St. Paul. These neighborhoods managed programs that coordinated elderly long-term home care services at the local level, supported family caregivers and utilized the services of neighborhood volunteers.
The Program Model
Using two successful community based senior care programs as a foundation, the Living at Home/Block Nurse Program has defined an operating model that combines the strengths of both programs. Centering on the needs of the individual and the individual's family, the Program is supported by neighbors and health care professionals who work together to meet the independent living needs of the individual. Data are being continuously collected by Programs to present practice outcomes and a proof of concept for public policy leaders.
The Program model identifies the capabilities of participants and their families, organizes resources in the neighborhood, integrates them with resources of the family and the wider community, and coordinates care and support to respond to the particular needs of older individuals. This collaborative approach is based on the knowledge that a long-term care program for elderly adults will thrive in communities where residents understand that interdependence is the foundation of their community and are committed to act in ways that benefit others.
The Program helps elderly people remain part of their communities and live as independently as possible with the use of appropriate services. It provides information, support services, counseling, and training for the family caregivers helping their elderly relatives remain in the community. It encourages the formation of additional in-home support services such as foster care and in-home day care for those who are unable to live alone in their own homes. In these varied ways the Program strengthens and enriches communities by encouraging neighborhood residents and local organizations to work together to help meet diverse needs of the elders in their community.
Program Model Guiding Principals
LAH/BNP, Inc.--through its educational arm, the Elderberry Institute--recommends a number of time-tested tenets for establishing and maintaining successful Programs, based on the experience and evaluation of the operating community Programs. These Living at Home/Block Nurse Program Guiding Principals may be downloaded from this website.
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Who governs the Program?
Initially, most Living at Home/Block Nurse Programs begin as an initiative of a group of local citizens who are interested in helping "their seniors" remain at home. In some cases Programs have begun as a joint venture with a local government entity (like a town or neighborhood council) or a church or group of churches. Sometimes a local non-profit or governmental entity serves as fiscal agent until the community Program can become a tax-exempt corporation. An initial steering committee (made up of interested citizens) and later a more formal board of directors in each community plans and directs the local Program, with assistance from the Elderberry Institute as needed. The board includes neighborhood residents and sometimes also involves representatives from agencies and organizations committed to local community control of the program (like the community hospital or public nursing service).
Most Programs begin by developing the "living at home" services, because these social and support services will involve and engage community volunteers and "only" require volunteer recruitment and coordination in order to provide immediate benefits to seniors. This initial phase also involves publicizing the Program to build community ownership and support as well as the active recruiting of senior participants.
A Program Director is recruited and selected by the local board of directors. Initially, the Program Director is often responsible for all program operations, including volunteer coordination activities. A Service (or Volunteer) Coordinator may also be hired if Program volume warrants. This position reports to the Program Director and is responsible for coordinating services to Program participants as well as recruiting, training, scheduling and supervising volunteers.
As more people learn about the local Living at Home/Block Nurse Program and a number of frail elderly begin to participate, the Program negotiates a joint venture with an existing nursing agency. The outcome of this collaboration is an innovative departure from the conventional service delivery system. No new nursing agency or health care provider is established to operate the "block nursing" component of the Living at Home/Block Nurse Program, but working closely with the Program, the agency partner selected by the local board becomes accountable for all nursing services provided to participants.
Nursing services staff are employed by the nursing agency, but are also accountable to the Program Director and work collaboratively with Program staff under the general policy direction of the local board. The overhead costs and administrative functions associated with employment of staff are either the responsibility of the nursing service (for nursing personnel) or the local Living at Home/Block Nurse Program (for Program staff).
The Primary Block Nurse is part of a team of public health nurses or visiting nurses and is responsible within the nursing agency system; she or he reports directly to a supervisor at the nursing agency, but is located at the Program office. The supervisor reports to the nursing agency administrative office.
The Living at Home/Block Nurse Program Director interviews job applicants, makes hiring decisions, and, when nursing services staff are being recruited, makes recommendations to the nursing agency. The Program Director manages and evaluates any non-nursing staff and in collaboration with the nursing supervisor of the nursing agency, manages and evaluates nursing services staff. The Program Director facilitates care conferences and generally manages daily operations of the Program as a whole.
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What services are coordinated by the Living at Home/Block Nurse Program?
(Link here to the Typical Services page data listed above)
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How does the Program work?
Enhancing the ability of a family to meet the needs of its own members is the cornerstone of the Living at Home/Block Nurse Program. The program organizes and reinforces what resources the family already has for meeting its own needs, and supplements those resources with a mix of services and supports from the neighborhood: nursing, counseling, transportation, bathing, errands and chores, socialization, physical therapy, and so on. These services are provided and coordinated under the supervision of a Program Director, Service Coordinator or a public health nurse (as need dictates) each of whom understands that the participant, family and community is the client.
Neighborhood residents needing help are identified in several ways:
- by the local LAH/BNP creatively reaching out to identify potential residents in need,
- by residents themselves,
- by family members,
- through word of mouth from friends,
- from contacts by churches and other community organizations,
- by referrals from hospitals, physicians, social service agencies
The program builds on neighborly interest in each other's well-being among local residents.
Service Coordination/Volunteer Assistance/Non-nursing Support
Each new participant is contacted by the Program Director or Service Coordinator. An initial assessment is completed and arrangements are made to supplement what resources the family already has for meeting this person's needs. Services from both formal and informal agencies are arranged and supervised by program personnel, who are (ideally) all neighborhood residents. The Service Coordinator may be a social worker, gerontologist or similar human services professional. Where possible, the plan for care focuses on assisting the resident to overcome barriers to independence, encourages and reinforces maintaining the current social and family support networks, and encourages the building of new networks as appropriate. Volunteers from the neighborhood are recruited and trained to provide needed assistance and support. The list of services described previously exemplify what can be done. Generally, the program tries to provide or help arrange whatever may be needed and to develop a tailored, personally specific approach for each participant.
Nursing Services
Each new nursing participant is assessed by the primary block nurse. The primary block nurse, a certified public health nurse with additional education in care of the elderly, meets with the person who needs nursing care and the family to identify what help is needed and to develop a specific, tailored care plan.
Where possible, the care plan focuses on assisting the participant to overcome barriers to independence. If needed, physical, occupational, and speech therapy are available from a rehabilitation center. The program also has ready access to acute medical care through the participant's physician.
Included in this case management is a gatekeeping function ensuring that only necessary services are delivered and that quality care is provided. Determination of an individual's needs is done in conjunction with the family and the family's physician when appropriate. In home professional and support services are coordinated with all services provided. Professional judgment determines the types and level of services necessary for maintaining an elderly person at home.
The Primary Block Nurse may:
- provide services directly or assign a block nurse, social worker or other professional
- arrange for a volunteer to teach and support the family to meet as many needs as possible · arrange for a volunteer to deliver and supervise care that the family is not able to provide.
The services of Block Companions (combined home health aides/homemakers) and Block Volunteers (befrienders, peer counselors) are also arranged and supervised as needed. These professional partners consult with each other on a regular basis and revise the care plan as necessary.
Local people interested in employment with a community Living at Home/Block Nurse Program (Program Director, Service Coordinator, or nursing services staff) are selected by the local program. Most positions are part-time and number of staff depends on the stage of development of the Program. Nursing services staff are employed by the nursing agency partner. They are oriented to the Living at Home/Block Nurse Program by Program staff, and having completed required courses, including gerontology, are assigned to individual clients in the neighborhood, under the direction of the Program Director and the nursing agency supervisor, as appropriate.
Registered nurses living within the neighborhood provide professional nursing care. Neighborhood residents who are trained as allied health professionals at a local vocational-technical institute provide home health aid, homemaking and chore services. Counseling and emotional support are available from two sources: neighborhood volunteers who are trained as peer counselors through a program developed by the University of Minnesota, and neighborhood church volunteers known as Befrienders who are recruited and trained through a program developed by the Wilder Foundation.
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How are the nursing services paid for?
Roughly 57% of the services are reimbursed by Medicare, Medicaid, Alternative Care or third-party insurance. Homemaker services for low-income participants may be reimbursed through several agencies such as under Federal Title XIX. Some home health services are reimbursed by Medicare, private insurance or Federal Title XX. In some states programs exist which provide "alternative care grants" for home care for low-income persons whom would otherwise require nursing home care.
Fees that are not reimbursed by one of the above sources are charged to participants on a sliding scale basis determined by the individual's ability to pay. These fees account for another 17% of reimbursement. When participants cannot pay the full amount, charitable contributions from private funders are used to cover the difference, which amounts to 26%. These funds are administered by the local Living At Home/Block Nurse Program Board or its fiscal agent. The average monthly cost per nursing client in all Living at Home/Block Nurse Programs is $300-500.
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What are the Program's principal benefits?
Better Service
Care in the home is usually more satisfying to participants than long-term care in an institution. Without the Living at Home/Block Nurse Program many elderly residents with temporary health problems or a general decline in functional/cognitive status and health would have fewer alternatives to a nursing home.
The Living at Home/Block Nurse Program makes care in the home possible in two ways:
- through resources to supplement the capabilities of families to meet their own needs, and
- by identifying and responding to needs for help sooner than the traditional service system, making it easier to remedy some conditions and to prevent others from occurring.
The Living at Home/Block Nurse Program draws on neighborhood resources not available to traditional health providers, building on a spirit of community self-help that extends the resources of a family. The program works with established training programs and institutions for a coordinated mix of volunteer, allied health professional and professional services. No comparable scope of service is available from conventional health and social service sources.
Traditional services that are available usually require a host of narrowly trained personnel coming into the client's home to perform discrete tasks. The Living at Home/Block Nurse Program avoids such disruption and fragmentation by combining job descriptions so that only a very few people are needed to perform a wide variety of tasks in one participant's home. It puts coordination and supervision of all personnel and support services under one individual, the Program Director, Service Coordinator or the Primary Block Nurse.
Lower Costs
Four factors contribute to a lower over-all cost of care:
- for people who can be helped to remain independent, care at home is less expensive than care in an institution
- the Living at Home/Block Nurse Program has developed methods to make in-home care less costly than is typically possible through the services of professional home care agencies. These methods include the use of local resources, savings on mileage and travel time cost, enhancement of the family's ability to meet its own needs, and the use of allied health professionals and volunteers, all with professional supervision
- only appropriate services in the amounts necessary are provided
- early diagnosis and treatment of health problems and the prevention of more serious problems both contribute to reduced long-term health care costs.
The fees for professional services under the Living at Home/Block Nurse Program are equal to or lower than fees for comparable services provided by conventional public and private agencies. By guaranteeing their nursing partner will incur no non-reimbursed service charges, the Program reduces that agency's cost of doing business and can negotiate service rate reductions in return. Some private nursing services may offer a lower hourly rate, but they typically require an hour minimum charge per visit, making the cost per case higher than that of the Living at Home/Block Nurse Program.
In at least one area, the Living at Home/Block Nurse Program incurs costs that the conventional health care delivery system often does not. It provides non-reimbursable services (such as personal care) and services to individuals who do not qualify for reimbursement under government programs or private insurance policies. Some of these costs are recovered through fees and others are covered through charitable contributions. The case can be made that many of these services prevent the participant's health or financial resources from dwindling to the point where that individual becomes the public's responsibility. Therefore, these services represent a savings to the larger community.
Proper Incentives
Unlike the conventional medical system, incentives under the Living at Home/Block Nurse Program favor:
- maximum self-reliance and minimum use of costly professional services
- early intervention and treatment of disabling illness
- prevention and recovery rather than long-term treatment
- and coordination and integration of services rather than fragmentation and specialization.
To the extent that fees and charitable contributions cover the costs of services to non-qualifying individuals who need help, the program avoids the incentives to institutionalize clients or over-diagnose needs in order to obtain public or third party reimbursements.
Quality of Life
Most important is the enhanced quality of life for elderly persons, their families and all who volunteer and contribute. Neighborhood volunteers care for their neighbors, and a sense of community ownership elicits the contribution of time, talent and dollars from the citizenry.
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What are the outcomes of this Program?
An external evaluation of the pilot Block Nurse program, completed in September 1985, documented that:
- Eight-five percent (85%) of the Block Nurse clients would be forced to enter nursing homes without home care.
- The total cost of living with Block Nurse care is at least twenty-four percent (24%) less than the minimum cost of a nursing home without nursing services.
- All indicators show that the Block Nurse Program tends to increase and enhance family involvement in the care of elderly relatives.
- Nine dimensions explain the qualitative distinctions between home health care programs and the Block Nurse Program: client-centered programming, coordination and integration of services, community-based staffing, prevention/recovery focus, early intervention, management of chronic illness/disability, delayed or reduced institutionalization, case-mix openness and fee flexibility.
- Block Nurse Program fees for Block Nurses and Block Companions (HHA/HM) are lower than for any other program surveyed, yet staff is paid according to community standards.
- The lack of a program policy requiring a minimum number of hours per visit is distinctive to the Block Nurse Program and in part accounts for its low fees.
Subsequent studies have supported these outcomes and documented high levels of participant, family and community satisfaction with the Program's outcomes. Findings like these in each of the community Living at Home/Block Nurse Programs are stimulating re-thinking about how communities spend their limited resources to meet the needs of rapidly growing elderly populations. For communities willing to meet senior's needs in the home rather than in an institution, and where quality and value of services are important considerations, the Living at Home/Block Nurse Program offers an attractive alternative to more traditional public and private services.
In addition to its financial benefits, the Program has implications for improving the quality and responsiveness of public services, enhancing the self-sufficiency of families and neighborhoods, and heightening the intimacy with which care is given. The Program suggests that neighborhoods can and should play a substantially larger role than they currently do in shaping and carrying out public services, that established public agencies and providers of innovative alternative services make better allies than adversaries, and that traditional definitions of public services need further critical examination. Perhaps many public services could be "de-professionalized", allowing for greater self-help and use of volunteers, calling on specialists to perform only those tasks for which special training is required.
As a model of caring for the elderly at home, the Living at Home/Block Nurse Program could be adapted to meet other neighborhood needs: nursing and support services for new mothers or sick children, child care, education, and job counseling. Where skilled and caring people live together in communities and have neighbors who need help, many opportunities may exist for responsive services based on the Living at Home/Block Nurse Program model.
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Can the Program be replicated in other communities?
Based on the results of the St. Anthony Park Block Nurse Program pilot in the mid-1980s, funding was sought to test the replicability of the model and to gather data that might be helpful for changing long-term care reimbursement policies. The Block Nurse Program was the recipient of grants from the W.K. Kellogg Foundation and the U.S. Department of Health & Human Services, Division of Nursing, totaling more than $1.7 million in January 1988. These funds were used to replicate the Program model in three diverse communities: two in St. Paul and a third in Atwater, Minnesota, a town of 1,100 including surrounding farming areas. This replication occurred over a 36-month period serving a total of 700 participants. Approximately 65% of the funds were used for non-reimbursable services and 35% for evaluation and administration.
A summary evaluation of the replication effort, and client and cost analysis done by the Metropolitan Council (MN) in 1990, documented among other findings, that:
- 42% of the referrals were by participants, family or friends
- 88% of the participants were aged 80-84
- 71% of the participants were women
- Average income of participants was $841 a month
- 60% of participants lived alone
- 49% needed assistance with activities of daily living
- 38% would be in nursing homes without the BNP
- Average cost per participant per month was $255*.
Another external evaluation of the replication in 1991 estimated that 38% of the clients reviewed would be in nursing homes without the Program. These nursing participants were being served at a cost of less than $500 per month, compared to about $2000 per month in a nursing home.
*Nursing home monthly average rates in St. Paul in 1990 were $1,654 for Case Mix A; of that, care related costs were $663 (food, housing, etc. have been subtracted).
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What awards has the Program received?
The unique importance of the Living at Home/Block Nurse Program model is reflected in awards received from Harvard University and the Ford Foundation's "Innovations in Local Government", AARP, "Neighborhoods, U.S.A.", the Midwest Alliance in Nursing, Minnesota Governor Rudy Perpich, the Ramsey County (Minnesota) board of commissioners, ARAMARK, the Metropolitan Council, the "Innovator of the Year" given by InterHealth and the 3M Corporation, and the St. Paul Area Chamber of Commerce Deubner Award for innovation and entrepreneurship.
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How do Program expansion and financing work?
Program Expansion
The Minnesota Department of Human Services along with a number of private foundations and charitable individuals have actively supported a resource center, called Living at Home/Block Nurse Program Inc. (LAH/BNP Inc.) to:
- assist communities to develop the Program,
- evaluate community readiness to provide the Program,
- maintain data base resources and
- act as liaison and a resource to states, federal agencies and legislatures.
As "keeper of the vision" the resource center supports the maintenance and development of Programs through its education and support arm, Elderberry Institute. Expansion of the Program model occurs in planned phases including:
- broad dissemination of descriptions of the model
- assisting new communities with creating their own Programs
- helping secure financial support for Programs in existing and start-up sites
- continually evaluating and publishing cost effectiveness and savings information to Medicare, Medicaid, Title XX
- initially expanding the Program throughout Minnesota and other states in the "heartland" of the United States (in 2000-2002 we are especially focused on working with communities wishing to start Programs in MN, ND, SD, IA, WI and IL).
As further support and funding become available the Elderberry Institute is extending these phases of assistance to a national audience, seeking funders and founders and equipping them to build new Programs in their neighborhoods and communities.
Program Financing
Operating funds for community Programs in Minnesota are provided by a combination of local funds raised by the neighborhoods (individual donations, in-kind contributions, gifts from neighborhood organizations and foundations), state funds, county and city funds. Nursing service funds are provided through existing reimbursement sources (additional waivers may be sought), recipients themselves (using a sliding fee scale) and a flexible pool of funds to meet individualized needs that the local Programs cover (using locally raised funds and/or additional waivers).
Community Programs in other states have followed variations on this theme. Most began under initial grants from local or national foundations combined with local
funds. These Programs are daily demonstrating the effectiveness and cost efficiencies of the Living at Home/Block Nurse Program model and documenting their outcomes. With this solid foundation of data and local support the Programs outside Minnesota are making a strong case for further support from their cities, counties and states. Elderberry Institute helps them in this effort with educational materials and personal contacts at the state and national levels.
Newly-organizing Programs in certain states may apply for matching grants from the Elderberry Institute Program Seeding Fund, established to assist local Programs with raising the funding to establish themselves in their communities. Several Foundations have generously underwritten the Program Seeding Fund. Requests for Proposals are solicited on a regular basis through this website, the network of elder-serving organizations, and press releases in the media.
Program Technical Support Fee
Elderberry Institute trains, certifies and provides Community Coaches who assist communities to replicate the Program in their individualized circumstances. These support services are underwritten from a variety of funding sources: statewide contracts, designated and undesignated foundation gifts, and ongoing Institute fundraising efforts. Where no technical support dollars are yet available for a new Program the Institute will provide assistance based on a tapered fee schedule to be paid by the Program.
Because our goal is to help new Programs succeed, the technical assistance in the tapered plan is heavily front-loaded while the fees are back-loaded. The schedule has been designed to allow payment over several years with payment amounts rising only as a Program gets on its feet financially and operationally. Fees are detailed in a Founder's Agreement negotiated between the Institute and the local Program.
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How do I get started building a Program in my community?
For further information about the Living at Home/Block Nurse Program and help getting started, contact:
Elderberry Institute, Suite 322
475 Cleveland Avenue North
St. Paul, Minnesota 55104.
(800) 320-1707
(651) 649-0315
Fax (651) 649-0318
email: elderb@elderberry.org
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