In collaboration with Somerset County’s Office On Aging,Community Home Care provides care to adult residents of Somerset County aged 60 and over who have been diagnosed with diabetes or congestive heart disease or have been classified “at risk” for the disease. This program provides education and supprt to empower older adults to gain control of their lives through disease management, medication compliance, adequate diet and nutrition, and lifestyle changes.

Services include:

       RN assessment, monthly visits and case management services

• Risk profile
• Physical assessment
• Glucose monitoring
• Oxygen Saturation monitoring
• Disease Management Education
• Environmental / Safety Assessment
• Pharmacist Medication Review
• Nutritional Counseling
• Social Work Evaluation
• Physical Therapy evaluation
• Telemonitoring (as indicated)
• Community referrals as needed

Services will be discussed with the patient and customized to best meet their needs. As this is a grant program, there is no charge to patients, nor does the patient need to be homebound.

To enroll in this program or to receive additional information, call our Community Services Coordinator at 908-725-9355 ext. 2201 or . 

Telehealth

Telehealth allows the nurse to monitor a patient in their place of residence. This is done through the use of a two-way audio-video unit involving the nurse and the patient, or a separate data unit.  The telemonitor unit has the ability to monitor blood pressure, pulse, glucose, heart and lung sounds and weight. This service provides remote care delivery of assessments, education and data collection. The clinical data is transmitted to the health care provider where clinical reviews can be updated.

Clients currently enrolled in this program are referred by the Somerset County Office on Aging.  Those who meet program criteria will receive disease management on a quarterly basis. 

ACCAP Case Management (AIDS Community Care Alternative Program)

Community VNS provides the Case Management site for Somerset County’s home and community based services waiver for persons with AIDS (Acquired Immune Deficiency Syndrome), formerly known as ACCAP. This program helps eligible individuals remain in their home under care giver supervisor, rather than admission to a long term care facility or hospital.

Eligibility requirements include nursing home level of care, a diagnosis of AIDS and financial limitations. Each individual’s service package is based on medical need and

must be no more than the cost of institutional care. Each recipient is required to share in the cost of the service package when needed expenses do not meet program criteria.

Enrollment to the program is determined by the Medicaid district office medical staff. Applications can be obtained from the County Board of Social Services or primary physician referral.

Disabilities Programs

Community VNA is the designated Case Management site for Somerset County’s Community Resources For People With Disabilities Program (CRPD), Model Waiver II and III. This program assists people with chronic disabilities to remain in their homes under caregiver supervision.  It provides additional funding and services to assist the clients long term medical needs.  For further information on services, including how to qualify and apply for the program, please call the Somerset County Board of Social Services or speak to your primary care physician.

ASSISTANCE TO FAMILIES AND INFORMAL CAREGIVERS