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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:

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:

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.

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.

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:

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:

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:

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.

An external evaluation of the pilot Block Nurse program, completed in September 1985, documented that:

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.

How Does the Community Senior Network Work?