TABLE OF CONTENTS
About
Why Collaboration
Innovative Models
New York State Hospital-Home Care Collaboration Model Highlight Videos
Statewide Collaboration Summit
Upcoming & Recorded Webinars
Webinar Archives & Related Resources
General Resources
Clinical Areas for Collaboration
Laws, Policies Governing Collaboration
Telehealth & Collaboration
Person-Centered Care for Collaboration
ABOUT
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.
WHY COLLABORATION
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.
INNOVATIVE MODELS
Employment in the healthcare field is outpacing all other sectors, with job growth in home care leading the way. Two new innovative models indicate a strong potential for success to help meet current and future demand for healthcare workers… and they can be replicated easily.
As part of the Hospital-Home Care Collaborative for COVID-19 and Beyond, the Home Care Association of New York State, the Healthcare Association of New York State and the Iroquois Healthcare Association highlighted two models focused on developing the healthcare workforce across the continuum of care.
Among the findings:
- Students participating in the Early College High School Health Sciences Program have higher grade point averages than non-participating students.
- In the Rhode Island Nurses Institute Middle College Charter High School, 90% of students were college and career ready. Sixty percent became licensed healthcare professionals and an additional 10% went on to graduate from college.
- In the class of 2021, 96% of students at the Rhode Island Nurses Institute Middle College Charter High School earned more than three college credits, with 54% earning more than 12 college credits.
Report available here.
The Blueprints for Collaboration are available here.
NEW YORK STATE HOSPITAL-HOME CARE COLLABORATION MODEL HIGHLIGHT VIDEOS
When hospitals partner with home health care providers to find new solutions to long-standing obstacles, patients recover more quickly and they do it at home– right where they want to be. Learn how these organizations came together & transformed patient care!
St. Peter’s Health Partners
New York-Presbyterian Queens & St. Mary’s Home
University of Rochester Medical Center & UR Home Care
STATEWIDE VIRTUAL WORKFORCE SUMMIT May 26, 2022
STATEWIDE HOSPITAL HOME-CARE COLLABORATION SUMMIT
Hosted on December 2, 2021
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.
WEBINARS
A Blueprint for a Collaboration Model
Early College for Aspiring Healthcare Workers in High School
M.S. Hall & Associates
December, 2022
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.
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.
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.
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.
Click here to view recording with Q&A
Click here to view presentation
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.
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.
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.
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.
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.
WEBINAR ARCHIVES & 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:
- 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.
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
- Compendium of Statewide Hospital-Home Care. Home Care Association, Iroquois Health Association, HANYS, 2023.
- 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.
- 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.
- Trends and Insights to Collaborate with Physicians, Care Teams, Patients and Family Members. Remington Report. 2021.
- Health Careers Information. Center for Health Workforce Studies. 2022. This website serves as a guide for anyone interested in a career in health care.
- Hospital-at-Home. American Hospital Association. 2022. Explore AHA’s growing repository of resources on hospital-at-home, including case studies and podcasts.
Integrating Primary Care and Hospital Care – Center for Care Innovations
CLINICAL AREAS FOR COLLABORATION
The following conditions are among those that account for a high number of potentially avoidable hospitalizations.
Sepsis
- 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.
Pressure Ulcers
- GoldSTAMP Collaboration Program to Reduce Pressure Ulcers. State University of New York at Albany School of Public Health.
LAWS, POLICIES GOVERNING COLLABORATION
- Public Health Law Section 2805-x: the Hospital-Home Care-Physician Collaboration Law.
- 2805-x Implementation Guidance from the New York State Department of Health.
- Statewide Health Care Facility Transformation Program III – NYS DOH, Applications must be submitted in Grants Gateway by 4:00 PM EST on Wednesday, January 12, 2022.
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.