Health care providers partner to enhance healing after leaving the hospital

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.

Adirondack Medical Center, 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 Program.

"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 works
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 period. 

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, Hamilton, Montgomery, Saratoga, Schenectady, 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 Hyde Medical Center, CVPH Medical Center, Elizabethtown Community Hospital, Ellis Medicine, Glens Falls Hospital, 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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