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.
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.
NEW YORK STATE HOSPITAL-HOME CARE COLLABORATION MODEL REPORTS
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.
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! 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
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.
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.
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.
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.
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.
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.
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.
Click here to view recording
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
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.
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.
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.
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.
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.
WEBINARS & RELATED RESOURCES
- 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.
- 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.
CLINICAL AREAS FOR COLLABORATION
- 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
- 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.