Under a grant from the Mother Cabrini Health Foundation, the Iroquois Healthcare Association (IHA), the Home Care Association of New York State Education & Research (HCA E&R), and the Healthcare Association of New York State (HANYS) 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, 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.



Over the past three years, our Collaborative has promoted and supported replication of prototype models of collaboration through presentations, education and technical assistance to hospitals, home care providers , physicians, health plans, mental health and other core partners statewide. In the last quarter of 2022, we developed four reports to assist the statewide healthcare community in ongoing health, mental health and aging services collaboration.

  • Compendium of Statewide Hospital-Home Care Collaborative Models ─ features prototypes of hospital-home care-physician collaboration models that offer transformative designs and major pre- and post-acute impacts. These models were featured in our statewide presentations and educational efforts.
  • Innovative Health-Mental Health Collaboration Models: A Primer ─ focuses on collaborative hospital-home care-mental/behavioral health models that foster interdisciplinary collaboration, prevent/better manage emergencies and avoid hospitalization and long-term institutionalization. This primer also profiles OMH supportive housing programs that help people with behavioral health needs who are entering the community or aging in place to be successful in the integrated settings.
  • Hospital and Home Care Partnerships with Aging Providers: Collaboration Models and Lessons Learned ─ HCA, HANYS and IHA collaborated with the Association on Aging in New York and several county offices for the aging to identify prototypes for hospital, home care and aging services collaboration. Programs highlighted in this report show how to improve aging in place and how to enhance older adults’ health through community-based aging services and healthcare integration. The highlighted models demonstrate that successful hospital, home care and aging services collaborations are multifaceted and provide a foundation for future collaborative work.
  • Collaborative Prototypes & Lessons Learned During the COVID-19 Vaccine Rollout ─ presents community collaboration models achieved by hospitals, home care and community partners in responding to the COVID-19 vaccination imperative. Regional vaccination hub leaders were invited to share major takeaways from these collaborations and to offer insights on other major healthcare delivery and public health goals beyond COVID-19 to which these lessons and practices could be applied.



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! Read the press release here.

St. Peter’s Health Partners

New York-Presbyterian Queens & St. Mary’s Home

University of Rochester Medical Center & UR Home Care


Hosted on May 26, 2022


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.


A Blueprint for a Collaboration Model – Rhode Island Nurses Institute Middle College Charter School
Date: November, 2022 – AVAILABLE NOW, WATCH BELOW

Collaborative Organization: Rhode Island Nurses institute Middle College Charter School

The Rhode Island Nurses Institute Middle College Charter School is a reinvention of nursing education. Research in the development of this school showed that the pathway to a nursing career begins before college. Students begin to investigate careers in middle school, and early influences dictate curriculum coursework and effort toward college.
The Nurses Middle College Network of Schools believes that the Rhode Island model can be replicated with the same outstanding outcomes. The Nurses Middle College Charter School in the capital region is opening in fall 2023 in Albany, NY.

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A Blueprint for a Collaboration Model – Early College for Aspiring Healthcare Workers in High School
Date: December, 2022 – AVAILABLE NOW, WATCH BELOW

Collaborative Organizations: Oswego Health, Fulton City School District and Cayuga Community College

Cayuga Community College, Oswego Health, and Fulton City School District partnered to create an early community college oathway for high school students who aspire to be nurses or work in the medical field. This partnership identifies potential health system employees early in their high school years and helps them develop a career pathway. The program is helping to redefine community, business, and educational partnerships for the lasting benefit of the local community.

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Models of Hospital-Homecare Electronic Health Record Integration
Date: May 12 – 12pm-1pm

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 a hospital-homecare model 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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Recent Webinar Sessions – available for download

Webinar: Collaboration of Care for patients with Mental Illness Across the Health system
Date: April 7, 2022, 12-1 p.m.

Collaborative Organizations: Catholic Health Services of Long Island, Mercy Hospital and Catholic Health 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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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-homecare collaboration.

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Webinar: A Blueprint of a Collaboration Model
Date: February 24, 2022, 12 – 1pm

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.

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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

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 Visting 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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Webinar: Acute Care at Home Model developed in the COVID-19 Surge
Date: Sept. 9, 12-1 p.m.

Collaborative organizations: Catholic Health (Long Island) and Catholic 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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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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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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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.

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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 WebinarIntegrated Care and Care Management Collaborative | Gurwin Health Care System, Stony Brook Hospital, Stony Brook Physician Practice

WATCH WebinarPre-acute/Post-acute Collaborative | Mount Sinai South Nassau, South Nassau Home Care

WATCH WebinarPopulation Health Collaborative and Analytics Partnership | Upstate Medical Center, Nascentia Health, Upstate Home Care

WATCH WebinarUtilizing 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








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