The Home Care Association of New York State (HCANYS), the Iroquois Healthcare Association (IHA), and IPRO, the state-federal regional quality improvement organization, partnered to develop and pilot Collaborative Models of Community Medicine and Paramedicine. This initiative involves a multiyear plan that is currently underway in five rural and small community regions that have developed pilots across New York State: Jefferson, Broome, Columbia and Greene, St. Lawrence, and Tompkins and Schuyler counties. Core health sector partners and practitioners from local hospitals, home health agencies, physicians, and emergency medical service organizations are working together to develop and implement collaborative models to strengthen care in their communities. Health sectors and health personnel must function together to make a collaborative, integrative program of this nature work.

Coordinating and optimizing the roles of all core partners in the delivery of care, particularly amid growing care complexity and shortage of resources, is critical to patient access, quality, and outcomes. The need for a coordinated response is exacerbated by the chronic and worsening health personnel shortages in the NYS healthcare system that impair access and continuity of care for medically, socio-economically, and mentally vulnerable individuals living in the community. Coverage and regulatory gaps in the healthcare system have severe consequences on individuals, the community, and priority public health concerns.

A key direction is the development and promotion of collaborative care by hospitals, physicians, home health agencies, and core community partners like EMS. While emergency care is traditionally the focus for paramedics and EMTs, they can play further invaluable roles in the overall system, and in partnership with patients’ care teams. They are frequently called into non-urgent medical situations, but in their current role are constrained to emergency response. This puts a burden on emergency care teams and threatens to harm those in true need of urgent or emergency care. By leveraging collaboration between emergency services and other health sector partners, this burden can be reduced while also ensuring patients receive appropriate and efficient care.

Traditionally, developing programs of community medicine in NYS that include elements of paramedicine is a challenge. Instead of focusing solely on statutory change, this initiative draws upon collaboration. This program is highly community-centered and requires consistent collaboration among providers. When providers collaborate and work together towards common goals, healthy communities are built.

Collaborative models aim to optimize resources and work with all key players towards goals to support care transitions, continuity of patient service, and coordinated intervention in vulnerable periods or vulnerable populations.  The goal is to avoid ED episodes and visits, reduce hospital readmissions, and avoid unnecessary hospitalizations and unnecessary ambulance transports. The pilots share similar goals, but each is tailored to the available community resources and the identified needs of the individuals living in each respective community.

The Jefferson County Pilot has started a successful effort to provide care across the hospital and home care spectrum. The foundation of the success thus far is attributable to continued education, communication, and trust-building across all core partners.

Related Resources

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. 

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.

HCA is also partnering with VNS Ithaca & Tompkins and Stonybrook/Gurwin to expand upon two collaborative models.

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.

• Compendium of Statewide Hospital-Home Care. Home Care Association, Iroquois Health Association, HANYS, 2023.
• Two Innovative Models Address Healthcare Workforce Challenges. Home Care Association, Iroquois Health Association, HANYS, 2022.
• Blueprints for Collaboration - Two Innovative Models Address Healthcare Workforce Challenges. Home Care Association, Iroquois Health Association, HANYS, 2022.
• 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.

Statewide Summits

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. 

Statewide Virtual Workforce Summit | May 26, 2022
Click Here To View The Workforce Summit Recording

Statewide Hospital Home-Care Collaboration Summit | December 2, 2021
Click Here To View The Summit Recording

Webinar Series

No login credentials needed to access recordings and handouts. If you did not attend or previously register, you can do so at the link to gain access to all recordings.

A Blueprint for a Collaboration Model
Early College for Aspiring Healthcare Workers in High School
M.S. Hall & Associates
December, 2022
Click here to view the recording
Click here to view the presentation

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.
Click here to view the recording
Click here to view the presentation 

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. 
Click here to view the recording
Click here to view the presentation

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.
Click here to view the recording 
Click here to view the presentation

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
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.
Click here to view recording
Click here to view presentation

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.   
Click here to view recording
Click here to view presentation

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. 
Click here to view recording
Click here to view presentation

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. 
Click here to view recording
Click here to view presentation

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.
Click here to view recording
Click here to view the presentation

CROWN & CARES Program for Managing Acute and Chronic Needs of COVID
WATCH Webinar

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.

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
WATCH Webinar | 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.

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 
WATCH Webinar

• Telehealth: Enhancing collaboration, improving care coordination: Nursing Management (lww.com)
• Using Telehealth to Improve Home-Based Care for Older Adults and Family Caregivers
• Patients in transition–improving hospital-home care collaboration through electronic messaging: providers’ perspectives – PubMed (nih.gov) 
• Age Friendly Health Systems. Institute for Healthcare Improvement.
• 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.
• Hospital-at-Home. American Hospital Association. 2022. Explore AHA’s growing repository of resources on hospital-at-home, including case studies and podcasts.
• How UVA Health’s Medicine HOME program reduces hospitalizations and readmissions | Healthcare IT News
• Collaborative Care Is Key to Reducing Hospitalizations
• Collaboration of Hospital Case Managers and Home Care Liaisons When Transitioning Patients: Professional Case Management (lww.com)
• Hospital and homecare nurses’ experiences of involvement of patients and families in transition between hospital and municipalities: A qualitative study – Petersen – Scandinavian Journal of Caring Sciences – Wiley Online Library
• How Collaboration Can Drastically Improve U.S. Health Care
• “Hospital at Home” Programs Improve Outcomes, Lower Costs, But Face Resistance from Providers and Payers

• Public Health Law Section 2805-x: the Hospital-Home Care-Physician Collaboration Law.
• 2805-x Implementation Guidancefrom the New York State Department of Health.

The Home Care Association of New York State Education & Research (HCA E&R) has been awarded funding from the Mother Cabrini Health Foundation to identify and address health disparities in populations receiving health care in homes and community-based services (HCBS) statewide.

This project includes a spectrum of components, including an assessment of disparities and potential interventions, a statewide diversity and cultural awareness education for all community based care organizations’ staff, a point of service translation pilot, a live-recorded training component for strategies and support for patients who have co-occurring behavioral health and physical health needs, a health literacy component for homebound individuals, a rural primary care collaborative, and engagement in Duke University’s “Population Care Coordinator Program” to train and certify clinicians in population care coordination.

Read more about each component and how you can get involved, below.

The initiative will pilot test the efficacy of providing virtual health literacy education and information to home care and hospice care recipients through the Virtual Senior Center (VSC), in partnership with Selfhelp Community Services, operator of the VSC. All home care, hospice, MLTC, FI/CDPAP and Waiver Program recipients encouraged to participate.

Health literacy has been defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” (Ratzan and Parker, 2000)

Health literacy is key to positive patient experience, outcomes, effective self-care, and partnership with care professionals. It is also critical in breaking through health disparities.

Your participation in this type of initiative will help equip you and your organization for advancement, and most importantly, will support your efforts to promote quality care and patient quality of experience, quality of life, independence and dignity.

Watch this compelling example of a VSC participant:

How to Enroll

The VSC contains an accessible menu of informational and educational material to support health literacy for recipients that can be directly accessed by the individual once they are enrolled. Individuals you identify, and who wish to enroll, will just need your help to be signed into the VSC.

Once enrolled, the individual (solo or with the assistance of their caregiver or family members) can access the elements of health literacy on the VSC. There is no limit to access; recipients can sign-in according to a schedule that works best for them.

There are no requirements other than to enroll, and to agree to provide feedback on the experience and benefit. Participating providers and organizations will be similarly asked to provide feedback and recommendations that HCA and the Mother Cabrini Foundation can use to evaluate and consider long-term support for the program.

At this link, you can enroll your client immediately by creating an account for them. The VSC team will keep HCA apprised (de-identified, no PHI) of the number of enrollees by organization and region.

Assessment of Disparities and Interventions

HCA E&R in conjunction with our project partner, IPRO, led a statewide assessment to explore disparities and interventions that assist with impacting care in HCBS. Read the full report on identified health disparities, corresponding gaps and barriers, and potential interventions here.

As a result of the assessment, respondents requested more information in in various areas. The following webinars were made available to fill the gaps identified from the assessment. The recordings are available on HCA’s LMS via the links below. 

Assessing and Addressing Social Determinants of Health by Adopting and Utilizing PREPARE.

This presentation provides an overview of the PRAPARE (Protocol for Responding to & Assessing Patients’ Assets, Risks & Experience) screening tool, implementation and action toolkit, available resources, and reviews PRAPARE codes including ICD- 10 CMS Z codes and others.

Collaborating and Knowing Your Community Partners and Resources

This presentation shares insights on successful partnerships, tips for navigating the challenges of creating new relationships, and reviews a Socioeconomic Risk Assessment tool, and a Community Resource Tool which includes county-level resources.

Best Practices for Collecting and Utilizing Patient Sociodemographic Data

This presentation reviews best practices for collecting and utilizing patient sociodemographic data used to identify and address disparities to ensure equitable care, and the impact of health-related social needs on health outcomes.

Mental Health Training

HCA in partnership with the New York State Office of Mental Health and the Finger Lakes Geriatric Center of the University of Rochester provided special training and educational curriculum for staff of home care agencies, hospice, MLTC and community mental health provider staff to advance the skills and knowledge of staff and the agencies’ organizational practices and strategies for the care and support of patients who have mental health interdisciplinary needs.

Recordings are now available for this specially-developed curriculum to enhance your practice knowledge and skills in the care of individuals with co-occurring physical and mental/behavioral needs; these are the individuals with the most complex, intensive and interdisciplinary needs; those who represent the greatest challenges in care; and those who far too often suffer the cracks of the fragmented physical-and-mental/behavioral health system.

The recordings will be posted on HCA’s new Learning Management System.

A New Tool Available To Help you Understand Delirium, Dementia, and Depression!

The Home Care Association of New York State Education and Research (HCA E&R) was awarded funding from the Mother Cabrini Health Foundation to identify and address health disparities in populations receiving health care in homes and community-based services statewide. HCA E&R in partnership with the Finger Lakes Geriatric Education Center held an educational webinar on December 15^th to provide an overview of Dementia, Delirium, and Depression, and introduced a new point-of-care tool to help you better understand the differences between the 3 D’s. Thomas Caprio, MD, Professor of Medicine and Director of the Finger Lakes Geriatric Education Center, provided an overview of the new tool, supplemental information, and a question and answer session. View the webinar here.

For access to the tool, please email This email address is being protected from spambots. You need JavaScript enabled to view it. and HCA E&R will send you the tool for use. We will follow up in a few weeks and ask that you fill out a brief survey on your experiences with the tool.

Translation Services

HCA E&R in partnership with Nascentia Health and five pilot agencies is conducting a point-of-care translation services for English language-challenged and non-English speaking individuals in home care. In addition to supporting the care of these individuals, the program will inform potential statewide replication goals.

Through this initiative, HCA and Nascentia Health have translated a number of resources in multiple languages prevalent in NYS. Among the resources are tools for providers and patients including sepsis zone tools, a general health booklet, and a tool differentiating between dementia, delirium, and depression. View the documents in HCA’s upcoming resource library.

Population Care Coordination

HCA has engaged Duke University’s “Population Care Coordinator Program” to train and certify clinicians in population care coordination focused at the community, organizational and patient level. This initiative is currently piloted in 10 agencies across NYS serving as the basis for evaluation and potential expansion for broader availability. 

Twenty two clinicians across NYS were engaged and certified upon completion of this training program.

Support for this partnership with Sepsis Alliance is provided in part by an independent educational grant from Pfizer, Inc.

Home Care Association of New York State Education and Research (HCA E&R), Sepsis Alliance and Eddy Visiting Nurse & Rehab Association (VNRA) developed patient education tools and resources to support complex infusion care at home under an independent educational grant from Pfizer Inc. 

 The educational program aims to educate chronic disease patients receiving anti-infective home infusions, and caregivers of these patients, about drug resistance. The key learning outcomes to be met in this project include:

1. Increased awareness and understanding of drug resistance concepts;  
2. How to monitor for signs of infection during the home infusion;  
3. The importance of following provider guidelines including follow-up; and  
4. Why effective anti-infectives are so important for chronic disease patients. 

In Year 1, we developed the patient education materials (zone sheet, brochure, and animated video) and recruited the following providers to test the materials. 

• Rochester Regional
• The Eddy
• VNA of Western NY

In Year 2, we administered the patient education material and tracked their progress through pre- and post- learning scores. Our goal was to educate 125 patients and analyze the effectiveness of the patient education.

Today, the resources are available for patients and caregivers to download at no cost from Sepsis Alliance.

Video Resources: Please share these video links with patients and their caregivers. 

• English version
• Spanish version

Print Resources: Please share these brochures and zone sheets with patients and their caregivers. The brochure and zone sheet are available in both English and Spanish.  

• Print Resources for home infusions

Questions? Please contact This email address is being protected from spambots. You need JavaScript enabled to view it..