Active Grant
Statewide Hospital-Home Care Collaborative for COVID-19 and Beyond
About
Hospitals and home care providers have long worked in a coordinated fashion. Pre-acute home care helps prevent avoidable hospitalizations, while post-acute home care helps in the recovery process.
Together these efforts ensure that patients do not end up admitted or readmitted to the hospital unnecessarily, so that hospitals can dedicate resources where they are most needed for emergency, critical, surgical, trauma and/or other specialty care.
This is especially important during medical surges, like in the COVID-19 pandemic, which has placed enormous stresses on hospital capacity, further necessitating strong mutual support partnerships across settings.
Under a grant from the Mother Cabrini Health Foundation, the Home Care Association of New York State Education & Research (HCA E&R) the Healthcare Association of New York State (HANYS) and the Iroquois Healthcare Association (IHA) have developed a Statewide Hospital-Home Care Collaborative.
The purpose of this program is to improve hospital-home care synchronization for front-end/pre-acute hospital care as well as far-end/post-hospital care, recovery, and long term support.
As part of this effort, IHA, HCA E&R, and HANYS have curated and hosted a series of webinars featuring prototypes of hospital and home care collaboration models that can be emulated by other providers statewide — working together, across settings.
HCA is also partnering with VNS Ithaca & Tompkins and Stonybrook/Gurwin to expand upon two collaborative models.
This initiative also includes a library of online resources and tools to assist hospital-home care collaborative development, provide technical assistance, and further education on identified collaboration needs and issues.
Reports and Blueprints
- Compendium of Statewide Hospital-Home Care. Home Care Association, Iroquois Health Association, HANYS, 2023.
- Two Innovative Models Address Healthcare Workforce Challenges. Home Care Association, Iroquois Health Association, HANYS, 2022.
- Blueprints for Collaboration - Two Innovative Models Address Healthcare Workforce Challenges. Home Care Association, Iroquois Health Association, HANYS, 2022.
- Innovative Hospital-Home Care-Mental Health Collaboration Models: A Primer Home Care Association, Iroquois Health Association, HANYS, 2023.
- 2022 Collaborative Prototypes & Lessons Learned During the COVID-19 Vaccine Rollout. Home Care Association, Iroquois Health Association, HANYS, 2023.
- Hospital and Home Care Partnerships with Aging Providers: Collaboration Models and Lessons Learned. Home Care Association, Iroquois Health Association, HANYS, 2023.
Collaborative Models—Statewide Summits & Webinar Series
Statewide Summits
Registered attendees will need to use their login credentials to access recordings. If you did not attend the Summit or previously register, you can do so at the link to gain access to all recordings.
Statewide Virtual Workforce Summit | May 26, 2022
Click Here To View The Workforce Summit Recording
Statewide Hospital Home-Care Collaboration Summit | December 2, 2021
Click Here To View The Summit Recording
Webinar Series
No login credentials needed to access recordings and handouts. If you did not attend or previously register, you can do so at the link to gain access to all recordings.
A Blueprint for a Collaboration Model
Early College for Aspiring Healthcare Workers in High School
M.S. Hall & Associates
December, 2022
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Models of Hospital-Homecare Electronic Health Record Integration
Collaborative Organizations: Montefiore Hospital and Montefiore Home Care
EHR integration is critical to effective health care services delivery, quality and value. It is an imperative in the evolving health care system and is a major threshold for collaborating partners. This webinar shares successful roadmaps and provides invaluable assistance to providers strategically exploring and planning EHR integration, particularly Hospital EPIC-system integration, with home care and other partners. Representatives from two hospital-homecare models – one upstate and one downstate urban – will share their approaches and successful experiences integrating EPIC with their hospital, home care and other network partners, and address important technical, programmatic and buy-in elements.
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Innovations in Care and Management through Hospital-Home Care Collaboration
Collaborative Organizations: Catholic Health System and Catholic Home Care
Collaboration is the pathway for innovating new models and solutions for patient care and for health system and population health goals. This webinar will present newest, cutting-edge designs for collaboratives being undertaken by a major hospital system and home health agency. It will delve into the newest areas and approaches employing collaborative strategies. Learn the latest from system leaders on how they are advancing the horizons of health program development and interventions through hospital-home care collaboration.
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Collaboration of Care for patients with Mental Illness Across the Health System
Collaborative Organizations: Catholic Health System and Catholic Home Care
Integration of physical and mental health services to at risk patients requires collaboration across the care continuum. Learn how one hospital and home care agency strove to move patients with mental illness seamlessly across acute care, outpatient and home care settings during the COVID-19 pandemic. A focus on telehealth greatly contributed to this collaborative model.
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A Blueprint of a Collaboration Model
Organization: M.S. Hall and Associates
M.S. Hall, strategic consultants in healthcare, will present a plan developed from a past collaboration model presented in last year’s Collaborative webinar series. This plan or “blueprint” will illustrate the principles around strategic design thinking and will be a “how-to” on replication of a particular model in a local community. You will learn how to think about a collaborative model based on nine building blocks of a business model canvas. The webinar will also focus on how you can use this canvas with various stakeholders to build a collaboration.
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Click here to view MS Hall – UR Collaboration Business Model
Click here to view MS Hall – UR Hospital and Home Care Collaboration Blueprint Narrative
Acute Care at Home Model Developed in the COVID-19 Surge
Collaborative organizations: Catholic Health System of Long Island and CHS Home Care
This session describes an effective collaboration between Catholic Home Care and Primary Care, developed by Catholic Health leadership, designed to care for and manage patients at home during the COVID-19 surge. Employing a patient-centric focus model, the primary goal of the project was to decompress the patient volume within system hospitals to allow for the management of the most acutely ill individuals while not comprising patient care and outcomes.
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Point of Dispensing Collaborative to Reach Underserved Populations
Collaborative organizations: Mohawk Valley Health System (MVHS) and Mohawk Valley Home Care
MVHS and Senior Network Health MLTC, part of MVHS’s Home Care Division, are using a Mobile point-of-dispensing (POD) team to reach underserved populations with COVID-19 vaccines. The Mobile PODs have already provided 1,325 vaccines while strengthening critical partnerships with local communities and community organizations. In this webinar, you’ll learn how to create a mobile team using all of your organizational assets and how to integrate this model into your community health improvement initiatives, particularly those that are addressing health disparities.
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Home Asthma Management, A Collaborative Effort to Reduce the Burden of Pediatric and Young Adult Asthma
Collaborative Organizations: St. Mary’s Home Care and New York-Presbyterian Queens
A special-needs home care agency and a New York City academic medical center have joined forces in a unique collaboration to address the needs of young patients with complex and chronic medical conditions. In this webinar, you’ll learn how the organizations formed a long-term relationship that started with a small pilot program and grew to an expanded collaboration with a broader network of the medical center’s multi-specialty physicians, increasing the number of in-home visits, patients enrolled in remote patient monitoring, and supportive services to further enhance quality of life.
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Complex Care Collaborative
Collaborative Organizations: St. Joseph’s Hospital, St. Joseph’s Health At Home, Trinity Health
This Hospital-Homecare-Physician collaborative focuses on the care and management of highly complex patients over a six-county service area. The model integrates service teams of a hospital, home health agency and physician-led Accountable Care Organization (ACO) to provide comprehensive, coordinated care for complex patient conditions and needs. It manages the care, prevents avoidable hospitalizations, rehospitalizations and institutional placements, optimizes and facilitates hospital discharge and transition of very challenging cases, and promotes value, efficiency and cost savings. In this webinar, project leaders will show how hospitals, home care agencies and physicians can design and navigate a collaborative model for the care of these neediest of cases.
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Emergency Department Diversion/Inpatient Admissions Collaborative Program for COVID-19 and Beyond
Collaborative Organizations: St. Peter’s Hospital and Eddy Visiting Nurse and Rehab Association
Preventable emergencies, ED visits and acute care admissions are systemic priorities. In this webinar, a major hospital and home care agency demonstrate how they partner for preventive intervention. The collaborative redirects emergency department and potential hospital admissions to patient-centered, appropriate and cost-effective care at home. The webinar will explain this win-win-win design, positive patient and system impacts, and key lessons for replication.
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CROWN & CARES Program for Managing Acute and Chronic Needs of COVID
WATCH Webinar
Patients at Home
Northwell Health and Northwell Home Care | Related Resource:
- Ambulatory Management of Moderate to High Risk COVID-19 Patients: The Coronavirus Related Outpatient Work Navigators (CROWN) Protocol. Home Health Care Management and Practice. October 2020.
High Risk/High Need Patient Collaborative
Nathan Littauer Hospital, Community Health Care Center of St. Mary’s and Nathan Littauer Hospital
WATCH Webinar
Critical Illness Recovery Program
University of Rochester Medical Center, URMC Home Care
WATCH Webinar
eMOLST Physician-Hospital-Home Care Collaborative
Dr. Patricia Bomba, NYU Hospital, Visiting Nurse Service of New York
WATCH Webinar | Related Resources:
- CompassionAndSupport.org
- Video: Thoughtful MOLST Discussions in Hospital & Hospice Settings. CompassionAndSupport.org.
- Video: Thoughtful MOLST Discussions in the Nursing Home Setting. CompassionAndSupport.org.
- MOLST Form and related resources. MOLST.org.
- MOLST General Instructions for Adults. New York State Department of Health.
- 8-Step MOLST Protocol. MOLST.org.
Integrated Care and Care Management Collaborative
Gurwin Health Care System, Stony Brook Hospital, Stony Brook Physician Practice
WATCH Webinar
Pre-acute/Post-acute Collaborative
Mount Sinai South Nassau, South Nassau Home Care
WATCH Webinar
Population Health Collaborative and Analytics Partnership
Upstate Medical Center, Nascentia Health, Upstate Home Care
WATCH Webinar
Utilizing Strategic Design to Foster Homecare-Hospital Collaboration Initiatives
M.S. Hall & Associates
WATCH Webinar
Collaboration Resources
- Telehealth: Enhancing collaboration, improving care coordination: Nursing Management (lww.com)
- Using Telehealth to Improve Home-Based Care for Older Adults and Family Caregivers
- Patients in transition–improving hospital-home care collaboration through electronic messaging: providers’ perspectives – PubMed (nih.gov)
- Age Friendly Health Systems. Institute for Healthcare Improvement.
- 5 ways Hospitals Can Boost Capacity Through Home Health. Advisory Board. 2020.
- Impact of Home Health Care on Health Care Resource Utilization Following Hospital Discharge: A Cohort Study. American Journal of Medicine. 2017.
- Innovative Home Care Models: Five Profiles in Cost Savings, Care Transitions. Simione Healthcare Consultants. 2012.
- Hospital-at-Home. American Hospital Association. 2022. Explore AHA’s growing repository of resources on hospital-at-home, including case studies and podcasts.
- How UVA Health’s Medicine HOME program reduces hospitalizations and readmissions | Healthcare IT News
- Collaborative Care Is Key to Reducing Hospitalizations
- Collaboration of Hospital Case Managers and Home Care Liaisons When Transitioning Patients: Professional Case Management (lww.com)
- Hospital and homecare nurses’ experiences of involvement of patients and families in transition between hospital and municipalities: A qualitative study – Petersen – Scandinavian Journal of Caring Sciences – Wiley Online Library
- How Collaboration Can Drastically Improve U.S. Health Care
- “Hospital at Home” Programs Improve Outcomes, Lower Costs, But Face Resistance from Providers and Payers
NYS Law and Policies Governing Collaboration
- Public Health Law Section 2805-x: the Hospital-Home Care-Physician Collaboration Law.
- 2805-x Implementation Guidancefrom the New York State Department of Health.