Hospital-Home Care Collaboration


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.

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. 


Acute Care at Home Model developed in the COVID-19 Surge

Date of live webinar: Sept. 9, 12-1 p.m.
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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Live Webinar: Point of Dispensing Collaborative to Reach Underserved Populations

Date: Sept. 29, 12-1 p.m. 
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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Live Webinar: Home Asthma Management, A Collaborative Effort to Reduce the Burden of  Pediatric and  Young Adult Asthma 

Date: Oct. 7, 12-1 p.m. 
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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Live Webinar: Complex Care Collaborative 

Date: Nov. 16, 2021, 12-1 p.m. 
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. 

Join Webinar Here on November 16: Accessible 15-minutes prior to session.

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Live Webinar: Emergency Department Diversion/Inpatient Admissions Collaborative Program for COVID-19 and Beyond 

Date February 3, 2022, 12-1 p.m. 
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.

Join Webinar Here on February 3: Accessible 15-minutes prior to session.

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Live Webinar: Models of Hospital-Home Care Electronic Health Record Integration 

Date: Feb. 24, 2022, 12-1 p.m. 
Collaborative Organizations: Montefiore Hospital and Montefiore Home Care; and United Health Services Home Care (invited) 

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-home care 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.  

Join Webinar Here on February 24: Accessible 15-minutes prior to session.

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Live Webinar: Innovations in Care and Management through Hospital-Home Care Collaboration 

Date: March 10, 2022, 12-1 p.m. 
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. 

Join Webinar Here on March 10: Accessible 15-minutes prior to session.

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Prerecorded Webinar: A Blueprint of a Collaboration Model  

Date: TBD – Stay tuned for available date
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 model.

Webinar access link coming soon.

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WATCH Webinar: CROWN & CARES Program for Managing Acute and Chronic Needs of COVID Patients at Home | Northwell Health and Northwell Home Care | Related Resource:

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:

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 



The following conditions are among those that account for a high number of potentially avoidable hospitalizations.


Pressure Ulcers