Hospital-Homecare Collaboration

DSRIP Project Name: Hospital-Home Care Collaboration Solutions (Project 2.b.viii)

Alliance staff contact: Nora Baratto | 518.701.2198Project Resources-01


Support patients in their homes as they recover following a hospital stay. Assist people in understanding their health conditions, the importance of following hospital discharge instructions, including taking their medications properly, while ensuring they have the medical and social supports necessary to avoid readmission.

Why does the community need this project?

Patients who previously may have been discharged from a hospital to home are now more likely to be discharged after a shortened hospital stay, and therefore in a more vulnerable state. Many patients and caregivers do not have the education or support in the home environment to manage medications and discharge instructions, making it more likely they will be readmitted to the hospital.

Project Goal

Reduce hospital readmissions by introducing enhanced discharge planning tools, care protocols and supports in the homecare setting.

Our Plan

  • Implement Interventions to Reduce Acute Care Transfers (INTERACT) or similar programs to ensure early identification tools are implemented, effective care coordination and monitoring of patients upon hospital discharge to a home setting.
  • Integrate electronic health records to reduce medication errors and other redundancies.
  • Create and deploy rapid cycle response teams to ensure sufficient home care services are in place for patients upon discharge