On-Site Registered Nurse

Lead Organization

Bethesda House of Schenectady

Joint Applicants

Ellis Medical Center’s Residency Program

Areas Project Intends to Serve

Schenectady

Overview

Bethesda House aims to reduce avoidable hospital use by providing care to some of the most underserved members of our society, homeless or unstably housed individuals who are frequently high utilizers of Emergency Departments. Bethesda House hopes to accomplish this by recruiting a full-time Registered Nurse (RN) who will provide on-site oversight, home visits, and community visits to the nearly 200 daily attendants of their facility in Schenectady, seeking to better manage patient health. Currently, many DSRIP participants experience difficulties in medication management and compliance, and accordingly, often fail to complete self-directed treatments as prescribed. As such, the RN will serve to assure treatment compliance and identify clients/patients who may require a higher level of medical attention for referral to Ellis’ Residency Program for further care, therefore more proactively managing patient health and ultimately reducing avoidable use.

DSRIP Measures Addressed

  • Behavioral Health
    • Discharge with Timely Follow-Up – 7 Days
    • Discharge with Timely Follow-Up – 30 Days
    • Potentially Preventable Emergency Visit
  • Avoidable Hospital Use
    • Potentially Preventable Admissions – Adult
    • Potentially Preventable Emergency Department Visits
    • Potentially Preventable Re-admissions