For VNA and its caregiving mission, fresh challenges lie ahead


In 2005, when I joined the board of the Vineyard Nursing Association (VNA), we operated out of cramped quarters at the old hospital, had about 40 employees, and sustained a loss of $100,000, despite strong support from the community. We had roughly $2 million in revenue that year and shared the homecare market here on the Vineyard with the Visiting Nurse Service (VNS), a division of Martha’s Vineyard Community Services.

Over the past eight years, we have diversified our business by adding services to meet the growing and changing needs of residents and visitors. We now provide private care on a sliding scale to supplement the needs of those who require more than insurance will cover. We play a critical role in end-of-life care, as the sole provider of home health aides to both Hospice agencies. We are the only certified homecare agency on Nantucket, having stepped in to help when Nantucket Cottage Hospital closed its homecare arm in 2010. Our community health programs now include town nursing clinics, health screenings, and chronic disease management, all of which are free. And our role in Island health care goes beyond providing direct patient services, as we have a leadership role on the Dukes County Health Council, contribute significant resources to the annual flu clinic, and participate on the Health Aging Task Force.

Historically, the VNA has acted as a safety net for patients leaving hospital care and for many senior citizens who do not have family or other caregivers nearby. The Islands do not have ample long-term care facilities, and do not have sufficient adult day health facilities for seniors, beyond the support provided by the MV Center for Living and the Councils on Aging.

Sadly, the VNA safety net model is no longer economically viable. Medicare and commercial insurance are increasingly focused on providing acute services and short-term care, and homecare agencies have been a prime target of savings on a national level. In 2014, other health care providers will begin to see dramatic changes: hospitals will be held accountable for the care of their patients after they are discharged; new insurance carriers will emerge under Obamacare; and cost-cutting measures across all health care sectors are inevitable.

In larger urban communities, these systemic changes are likely to be manageable. To be sure, small agencies may go out of business, but other outfits, as a matter of simple geography, will fill the void. In some Boston suburbs, for example, you may have 20 or so certified homecare agencies from which to choose. On Martha’s Vineyard and Nantucket, the VNA is it.

As the VNA faces these challenging times, we are committed to not allowing patient care to suffer. We have a compassionate, hard-working staff and a dedicated board. But the structural circumstances I have noted compel us to act now. The economics of the changing homecare equation dictate that we find a new model of care and service delivery to help us better absorb the changes in the Medicare reimbursement scheme and to leverage the skills of our nurses and aides in new areas. This is not a problem for the VNA to solve in isolation — the ramifications are too critical for individuals who rely on us every day and for the community at large.

So what does all of this mean? It means that, at this time next year, the VNA will not be the same organization it is today. Two possible outcomes seem likely. We will either be acquired and will operate under the control and management of a larger, off-Island based homecare entity, or we will join, in one form or another, with organizations closer to home. In the first scenario, we would immediately gain technical expertise and add the leverage which comes with size. We would forego, however, Island-based control and perhaps sensibility over our operational decisions. In the second scenario, our community health leaders would have the opportunity to take charge of Island homecare and to preserve local control. That path would necessarily require greater private support and demand more creativity to figure out how best to use the VNA’s assets and experience to capitalize on emerging opportunities for homecare providers.

I cannot today predict for you how things will work out. The next few months will tell us much. My hope and my expectation is that homecare on the Islands will not only survive, but will thrive in the changing times ahead. We are confident that our neighbors and friends will be able to continue to count on home visits from the knowledgeable, the reliable, and the empathetic professionals from whom they have become accustomed to receive care during recovery and treatment.

I thank the community for its past support and overwhelming response to our recent appeal. Stay tuned to our developments, and I look forward to 2014 with caution but also with renewed optimism. Best wishes.

Michael Goldsmith is a director with the law firm Reynolds, Rappaport, Kaplan & Hackney, LLC, where he is a litigator focusing on municipal, zoning, and land use cases. He has been a summer visitor and resident since the 1960s, and has lived year-round on the Vineyard since 2000.