Health care providers partner to enhance healing after leaving the hospital
October 8th, 2012
SARANAC LAKE - Adirondack Health
and High Peaks Hospice & Palliative Care have teamed up to help Medicare
patients continue the healing process after they leave the hospital to lower
the potential they are unnecessarily re-admitted.
a member of Adirondack Health, and
High Peaks Hospice are part of the North Eastern New York Community-based Care
Transitions Program (CCTP), a consortium of 16 upstate New York
hospitals and health-care organizations that serve people in ten counties. In the Tri-Lakes region, the collaboration
between AMC and High Peaks Hospice is known as the Adirondack Care Transition
"We are very excited to be partnering with High Peaks
Hospice on this initiative," said Margaret Sorensen,
Chief Nursing Officer for Adirondack Health. "The Adirondack Care Transition Program is an
extension of our commitment to top-quality patient-centered care, with a
special concern for the health needs of the elderly."
How the initiative
People who are enrolled in a traditional Medicare fee-for-service, and
are at particular risk of health concerns after being discharged, are eligible to
join the care program. There is no
charge to participate as the cost of the program will be paid by Medicare and
participating health-care organizations.
Patients who choose to participate will meet with Registered
Nurse Aimee Savarie prior to going
home and develop a care plan to achieve a personal goal previously out of reach
due to the patient's health condition. A
goal can be attending a grandchild's soccer game or enjoying a picnic with friends. The patient will identify steps to achieve
his or her personal goal, and to recognize red flags that may slow recovery.
Once the patient is back at home, Registered Nurse Tracy
Posdzich from High Peaks Hospice and Palliative Care will serve as "health
coach" and provide support through
regular visits or answering questions by telephone.
The program will operate locally for two years during which
the Centers for Medicare & Medicaid Services will determine if it meets the
goals of keeping people healthy and reducing
preventable hospital re-admissions.
Participation in CCTP may be extended on an annual basis for the
remaining three years of the program if performance targets are met.
The CCTP is an initiative of the
Partnership for Patients, a nationwide public-private partnership launched
in April 2011.
The goals of the partnership:
- Aim to cut preventable errors in hospitals by 40 percent
- Reduce preventable hospital re-admissions by 20 percent over a three-year
The goals of CCTP are:
- Reduce hospital re-admissions
- Test sustainable funding
streams for care transition services
- Maintain or improve
quality of care
- Document measureable savings
to the Medicare program
The ten-county region covers Clinton,
Essex, Franklin, Fulton,
Warren and Washington
counties. There are over 100,000
traditional Medicare beneficiaries in the region, and about 25,000 of them are
hospitalized over the course of a year.
Of these, about 5,500 are expected to participate in the CCTP.
The lead agency for the regional consortium is the Visiting
Nurse Service of Schenectady and Saratoga
Counties, Inc. Other participating
organizations are: Alice
Ellis Medicine, Glens Falls
Inter-Lakes Health, Nathan Littauer Hospital,
St. Mary's Healthcare (Amsterdam),
Saratoga Hospital, Adirondack Health
Institute, Community Health Center,
High Peaks Hospice, Hudson Headwaters Health
Network, Saratoga County Office for the Aging, and Washington County CARES.
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||AMC is accredited by the Healthcare Facilities Accreditation Program.
||Adirondack Medical Center's Bariatric Program and Dr. Michael Hill have been designated as a Center of Excellence by the American Society for Bariatric Surgery.