Home Care Profiles of Innovation

Throughout New York, home care providers are innovating. They are maximizing their role beyond what many in the public might recognize as home care, reducing costs and providing sophisticated forms of care where most patients want to receive it.  

Home care nurses, therapists, social workers, aides and hospice professionals form critical teams. They are using technologies, skilled assessments, expedited case management, triage protocols and new program designs to prevent hospitalizations or reduce hospital lengths of stay for the most high-cost conditions. They are doing so through new levels of coordination with physicians, hospitals and other partners.

They are identifying gaps – and filling them in – to provide chronic-care management services and hospital after-care. They are meeting unmet needs, and responding to the needs of the whole person. Read some of their stories below. 

Pediatric Home Care Feeding Program Helps Children Wean from Feeding Tubes

Organization: St. Mary’s Healthcare System for Children. Areas served: NYC, Long Island, Westchester, Rockland.

In-home nursing and therapy services, paired with innovative technological tools, are helping children wean off feeding tubes thanks to a pediatric feeding program led by St. Mary's Home Care.


Home Care Lymphedema Program Vital to Cancer Recovery

Organization: Community Health Center of St. Mary's Healthcare and Nathan Littauer Hospital. Areas served: Fulton, Montgomery, Hamilton, Herkimer, Schoharie, Warren.

For breast cancer surgery or radiation therapy after-care — as with many forms of post-acute care — home health RNs and PTs provide skilled wound services, medication assistance, therapies to help with range of motion or to treat fluid build-up, as well as other relief for patients and families coping with disease, illness and recovery. Therapists like Kristen Anuszewski are bringing this sophisticated level of care to areas of rural New York.


Evidence-Based Practices Inform Pediatric Autism Interventions, Peer Training Program in Home Care

Organization: Americare. Areas served: NYC, Long Island, Westchester.

For a child diagnosed with Autism Spectrum Disorder (ASD), routine is fundamental. The home care environment is a place where routines can best be controlled. Diloram Kamilova, RN, of Americare Certified Special Services is taking charge of this work headlong, helping to train and educate her peers through evidence-based practices and interventions for ASD.


In-Home Wound Care Program Helps Patients Heal Faster

Organization: UR Medicine Home Care. Areas served: Livingston, Monroe, Ontario, Seneca, Wayne, Wyoming, Yates.

Approximately half of all patients served by UR Medicine Home Care are afflicted with some type of wound and/or ostomy complication, as patients are increasingly discharged from hospitals with greater and more complex needs. To meet such needs, this nationally recognized agency in the Rochester region has developed an innovative Wound and Ostomy Care Program. It is delivering specialized care expertise and education for individuals who would otherwise need costlier services.


Specialized Home Care for Holocaust Survivors at Selfhelp Community Services

Organization: Selfhelp Community Services. Areas served: NYC, Westchester, Long Island.

By 2025, approximately 23,400 Holocaust survivors are projected to still be living in the New York Metropolitan area. As a population, they are getting older and more frail. Their needs are increasingly complex, compounded by the trauma of their experience during the Holocaust. Selfhelp Community Services is providing specialized care to help.


People, Inc. Reduces ER, Urgent Care Use by 25% with Innovative Home Care Protocols, Technology

Organization: People, Inc. Areas served: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming.

Inspired by the state’s DSRIP initiative, People, Inc. of Western New York tested a standardized best-practice model of care paths and triage software to reduce hospitalizations by 25% among 950 individuals with intellectual and developmental disabilities, a medically at-risk population.


St. Joseph’s Home Care Collaborative Model

Organization: St. Joseph's Hospital Home Care. Areas served: Onondaga, Oswego, Madison, Cayuga, Lewis, Cortland.

Syracuse-based St. Joseph’s Hospital Certified Home Health Agency (CHHA) is building on its role in achieving cost and quality targets for all of St. Joseph’s health system — thanks in large part to a relatively new state program allowing for collaboration and regulatory flexibility in home care’s work with other partners.


Technology, Rapid Case Management Help Essex County Home Care Reduce Hospital Admissions by 60%, Bridge Geographic Divides

Organization: Essex County Department of Health Home Health Unit. Areas served: Essex.

Using a cutting-edge remote-monitoring platform, Essex County's home care unit is changing patient behavior, providing rapid response case management, reducing hospital readmissions and improving clinical outcomes. Perhaps best yet, the program is putting patients in more direct charge of their health.


Home Care Pediatric Asthma Program Treats Third Leading Cause of Hospitalizations

Organization: St. Mary’s Healthcare System for Children. Areas served: NYC, Long Island, Westchester, Rockland.

St. Mary’s Home Care has a multi-pronged approach to pediatric asthma management involving a home assessment program and a separate set of remote patient monitoring pilots that the organization has advanced with hospital partners under the Delivery System Reform Incentive Payment (DSRIP) program. Patients in the program had zero hospitalizations in the first year of implementation, with 88 percent of families able to demonstrate asthma skills taught by the St. Mary’s specialists and 85 percent having an asthma action plan.