NFMMC Home Visit Program: Meeting People ‘Where They Are’


Millennium Collaborative Care has been proud to extend Delivery Service Incentive Payment Program support, including Innovation Fund support, to innovative initiatives under the leadership of Sheila Kee, Executive Vice President and Chief Operating Officer, that are currently addressing social determinants of health and improving the delivery of healthcare for patients at Niagara Falls Memorial Medical Center in Niagara Falls, NY.
Sincerest thanks to NFMMC team members for sharing insights into their daily efforts to provide compassionate, comprehensive care, and truly make a major difference in their patients’ lives.

Chenelle Cruz LMSW, Mental Health Therapist

NFMMC Home Visit Program

By Chenelle Cruz LMSW, Mental Health Therapist

When I began home visits in July of 2018, I was eager to go to the client’s homes and get a better understanding of who they were and really see their environment rather than a professional setting.

Meeting them on their turf, in their personal space, a place they called home, where they found comfort, or so I thought. I quickly learned how important building a rapport with the client would be. Home Visits also allowed me to better link them to services that may have been missed or unnoticed while in the hospital. I needed to show them that I was not the stigmatized “white coat” there to judge them or criticize them. I wanted them to feel comfortable with me and be able to not only let me in to their homes but most importantly for them to open up to me about more personal subjects; their mental health.

Providing the clients with a free meal was a great way of “breaking bread”, building a relationship with the client thus reducing suspiciousness and increasing trust. Home visits bridge the gap between the Inpatient and Outpatient units, allowing a strong continuum of care.

Home visits allow us to meet the client where they are at. Both literally and figuratively. I have met clients at the bus terminal, grocery store, client’s employment, and in my vehicle. Often clients are homeless and struggle to find a warm safe meeting place during the cold winter months. Agreeing to meet them where they are shows the clients that we are working towards their best interest and we can accommodate to their needs, thus building a strong rapport in hopes of better continuum of care.

While in the home I was able to see what some of the real barriers to care were. I was able to get a firsthand view of the clients living situation (the neighborhood, overcrowding, presence or absence of food in the cupboards, medication, supplies, hygiene), and a sense of their organizational abilities.

I quickly learned one huge barrier to their care was medication adherence. I was able to see the piles of medication that they would sift through, some outdated, some new and the majority of clients did not know what the medication was for. Leaving them struggling with the same symptoms they were seen and treated while they were Inpatient. Creating a revolving door of care.

Another barrier that I saw was situational depression.

Many of the clients we met with struggled with adequate housing. I made home visits in communities that were predominantly low income, subsidy housing. While on a home visit we presented to a home of a young women who lived in a basement that appeared to be added to an apartment complex. Low ceiling, poor up keep, and crumbling foundation and walls.

While in the home, the client presented appreciative and engaged with our visit. Her apartment was her home, candles lit, and clean to the best of her ability, however, appeared to have dirt floor. The client was grateful for the free meal and discussed barriers to her mental health such as situational depression and anxiety that has led her to ongoing suicidal thoughts and prior inpatient visits.

We were able to gain a better understanding of her depression and were able to link her with follow up mental health appointment. Going on these home visits showed me a different perspective to the clients we treat daily lives. Living in housing such as this created even more depression and anxiety for them.

Lastly, the home visits showed me that you never truly get a good understanding of our clients until you meet them in their environment. You see their living arrangements. I understand why many of them seek inpatient services so often. There are many benefits of the home visits. Being an extra pair of eyes and being able to help another person who is in need.



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