Ambulatory Home Visits

Lead Organization

Community Care Physicians

Joint Applicants

Helderberg Ambulance

Areas Project Intends to Serve

Sections of Albany, Schenectady, and Schoharie counties

Overview

Community Care Physicians and Helderberg Ambulance seek to increase access to preventative care and reduce avoidable hospital use in the rural edges of the Capital Region around Berne, Knox, and Westerlo, where a single physician currently serves over 1,800 patients, many of whom are elderly or disabled and have no reliable transportation. The proposal aims to combat the fact that these patients often only seek care once they have reached critical conditions through the employment of “Vitalists,” who will maximize patient contact in the community. Vitalists will serve to gather patient’s vital signs as well as other information pertaining to social determinants of health in the comfort of their homes, and then transmit that information directly to the doctor to proactively manage patient health and prevent acute crises.

DSRIP Measures Addressed

  • Preventative Health
    • Primary Care Visit (All Ages)
    • Well Child Visit (All Ages)
  • Avoidable Hospital Use
    • Potentially Preventable Admissions – Child
    • Potentially Preventable Admissions – Adult
    • Potentially Preventable Emergency Department Visits
    • Potentially Preventable Readmissions