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 Collaboration program.
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, HCA E&R, HANYS, and IHA 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.
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.
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.
WEBINARS & RELATED RESOURCES
WATCH Webinar: CROWN & CARES Program for Managing Acute and Chronic Needs of COVID 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.
WATCH Webinar: 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 | Related Resources:
- 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.
WATCH Webinar: 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
GENERAL COLLABORATION RESOURCES
- 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.
CLINICAL AREAS FOR COLLABORATION
The following conditions are among those that account for a high number of potentially avoidable hospitalizations.
- Stop Sepsis at Home NY Screening Tool. Home Care Association of New York State.
- Sepsis in Home Health Care. October 2020. Journal of Nursing Care Quality.
- Does Early Follow-Up Improve the Outcomes of Sepsis Survivors Discharged to Home Health Care? August 2020. Medical Care – Journal of the American Public Health Association.
- GoldSTAMP Collaboration Program to Reduce Pressure Ulcers. State University of New York at Albany School of Public Health.
LAWS, POLICIES GOVERNING COLLABORATION
TELEHEALTH & COLLABORATION
PERSON-CENTERED CARE FOR COLLABORATION
- 8 Step Change Process for Improving Transitions of Care. Planetree.
- Person-Centered Guidelines for Preserving Family Presence in Challenging Times. Planetree.
- Age Friendly Health Systems. Institute for Healthcare Improvement.
- New York State Action Community. HANYS.