Implementation of INTERACT-like program (Interventions to Reduce Acute Care Transfers) in the home care setting to reduce the risk of re-hospitalizations for high risk patients.
Many patients who previously were transferred to skilled nursing facilities are now being discharged to lesser restrictive alternatives, primarily their own home. With the many benefits of returning to a known and personal setting, there are the risks of potential non-compliance with discharge regimens, missed provider appointments and less frequent observation of an at-risk person by medical staff. This project will put services in place to address this problem. It may be paired with transition care management, but the service would be expected to last more than 30 days.
Chronically ill and/or high risk individuals.
- Project Requirements, Milestones and Metrics
- AHI PPS DSRIP Project – Telehealth Implementation Survey, April 2016
- Advance Care Planning – a booklet that provides an overview of advance care planning and outlines why patients should explore and clarify their goals of care through written documents.
- Don’t Reinvent the Wheel – Home Care is Already Your Hub for Community-Based DSRIP and Value Based Services – What every DSRIP committee and Value Based Payment leader needs to know about partnering with home care from the Home Care Association of New York.
- Home Care Across the Continuum – We Are More Than Long-Term Care – Consider Home Care for innovative program design and partnerships to leverage its expertise in primary care, post-acute, long-term and end-of-life care to reduce ED visits, readmissions, improve outcomes and reduce costs, from the Home Care Association of New York State.
- Hospital Guide to Reducing Medicaid Readmissions – an ARHQ toolbox.
- Huddle for Care – “huddle stories” are ideas for inspiring transitional care solutions.
- INTERACT™ vs. Home Health Agency Crosswalk – developed for home health agencies to assess their current system/processes/or tools in order to understand what aligns with the INTERACT™ program, and to help identify potential gaps.
- Interventions to Reduce Acute Care Transfers – this website provides information on the INTERACT™ program and gives an overview of the three basic types of INTERACT™ tools (communication tools; care paths or clinical tools; and advance care planning tools).
- TeamSTEPPS Rapid Response Systems Module – free online training on rapid response teams and systems.
- Hospital-Home Care Collaboration Solutions – a PowerPoint presentation that includes a high level overview of DSRIP, Project 2.b.viii, and the INTERACT™ tools.
|Meeting date||Meeting Overview|
|October 16, 2015||AHI Regional Kick-Off Meeting – Transitions of Care (2.b.viii & 3.g.i)|