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Steve Ross knows if he tries skipping an appointment, there are experts keeping him on track 

Steve Ross isn’t sure how many medical appointments he would have kept if not for Heather Hunneman. 

“I was always calling, trying to cancel … and probably wouldn’t have made all my kidney appointments,” Ross muses. “If it wasn’t for Heather (a registered nurse with The University of Vermont Health Network – Home Health & Hospice), I just didn’t have enough strength and wherewithal to do it on my own.” 

“Heather can be very persuasive” about the importance of regular medical care, Ross adds with a laugh. 

Ross is one of 35 Vermonters with chronic health conditions benefitting from careful at-home monitoring through a growing program with a mouthful of a name: Longitudinal Care. In its first three years, the Longitudinal Care program, launched at Home Health & Hospice in 2018 with a OneCare Vermont grant, aimed to reduce hospital visits and readmissions. It’s had greater success than anyone could have hoped: Emergency visits and hospitalizations dropped more than 55% among enrolled patients. 

Early detection and monitoring

Ross, and patients like him, benefit from a team committed to managing health conditions and preventing crises by coordinating timely essential care . Much of that care is provided in the safety and comfort of home. 

“Successes hinge upon careful monitoring, early detection and intervention, and ongoing support around managing chronic illnesses,” Hunneman says. She and her colleagues maintain regular contact with patients like Ross through telemonitoring, 24-hour phone support and regular nursing contact. During in-person and virtual visits, Home Health & Hospice clinicians review medications, provide education and attend medical appointments as patient advocates. 

Hunneman saved Ross trips to the hospital for blood draws; she also brought greater clarity to medication dosing and treatment schedules, and offered pointers for increased home safety. “I can’t think of all the little things that she did for me, but it was a lot,” says Ross.  “She could talk to the doctors when I couldn’t understand what was going on.”  

Building trust 

Trust is essential to any good relationship. The rapport Ross shares with Hunneman and other members of the team is instantly apparent. 

Ross “letting (the Longitudinal Care team) come into his house was a huge deal,” Ross’s sister Sally observes. “Heather just had the right personality. He clicked right away with her and he clicked right away with Maddie (Ruth, community health worker). It was just such a great connection for him to have with people that weren’t me.”  

Ruth regularly notifies the team of additional social service or medical needs. This was never more crucial than after Ross had fallen repeatedly. 

“I was having this problem where I kept falling out of bed,” he explains. Ruth “came to one of the visits and found me at the bottom of my stairs, just sitting there, looking off into space.” She called 911, contacted her nursing colleagues and monitored Ross while awaiting medical support. “She said, ‘I’m not leaving Steve until he gets some help,’” he recalls. “She is always just a pleasure to see and a boost to my spirits.” 

The importance of connection

“Relationship building is the key to helping clients improve their own self-care abilities with the goal being to keep our folks at home and out of the hospital as much as possible,” Hunneman said. She and her colleagues aim to improve patient experiences and outcomes, prevent acute health care episodes, support transitions from acute illness to relative wellness and empower patients and families in their own care.

By coordinating with primary care providers, specialists and social services, the team helps patients and families better understand and manage conditions to stay healthier. 

Building on success 

Home Health & Hospice’s Longitudinal Care model is so successful that the team is leading trainings with other VNAs of Vermont interested in replicating the program. This is good news for patients, their families and the community, faced with increased hospitalizations due to COVID-19. Staying ahead of emergencies remains critical.

“I was always calling, trying to cancel appointments and Heather said, ‘Well, I’m glad you didn’t try to call and cancel this appointment,’ she said, ‘because we’d have come anyhow,’” Ross recalled with a laugh. 

To learn more about the Longitudinal Care program, call 802-658-1900 or visit uvmhomehealth.org.