Local Healthcare Organizations Approved for Federal Program

Friday, January 18th, 2013

The federal government has offered an initiative program designed to help patients covered by Medicare get better faster after they are discharged from the hospital. The Center for Medicare and Medicaid Services has approved three local healthcare organizations. Community Health Center, acting as the community based organization for Nathan Littauer Hospital and St. Mary's Healthcare, is part of the North Eastern New York Community-based Care Transitions Program (CCTP), a consortium of 16 upstate New York hospitals and healthcare organizations, which serve people in ten counties from the Vermont and Canadian borders south and west to Schenectady and Amsterdam.

The CCTP is an initiative of the Partnership for Patients, a nationwide public-private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three-year period. CCTP's goals are to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program.

Laurence E. Kelly, Nathan Littauer Hospital President and CEO, notes, "We have a special concern for the health needs of the elderly and this program is in keeping with our mission to serve all people with the highest level of care possible."

Victor Giulianelli, President and CEO of St. Mary's Healthcare, notes, "As St. Mary's Healthcare strives to improve the patient-centered experience, the Care Transitions philosophy will help us to engage patients and their caregivers to become equal partners in health care planning.  This will be a key driver to reduce readmissions and promote individual health and well being."

Mildred P. Ferriter, Executive Director of the Community Health Center, states, "In serving our hospitals and communities, CHC is proud to play an integral part of this new initiative to enhance patient outcomes using the approach of patient centered care through coaching and teaching. We are very excited about the Care Transitions program and the opportunity to provide this program to our community."

People who are enrolled in traditional Medicare fee-for-service and are at particular risk of problems after being discharged, such as people with heart conditions or patients who have been in and out of the hospital before, will be eligible to receive the service.

If a patient decides to participate, before they leave the hospital a nurse will help plan the care they will need when they get home. Then, soon after they get home, a nurse or a "health coach" will visit the patient to be sure that they have the right medications and support. Nurses and coaches will be available to answer questions by telephone, and will make follow-up calls and visits.

There will be no charge for patients to participate, as Medicare and the participating hospitals and healthcare organizations will pay costs. The program will operate locally for two years during which the Centers for Medicare and Medicaid Services will determine if it meets its goals of keeping people healthy and out of the hospital. Participation in CCTP may be extended on an annual basis for the remaining three years of the program if performance targets are met.

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. The other participating organizations are: Adirondack Medical Center, Alice Hyde Medical Center, Champlain Valley Physicians Hospital, Elizabethtown Community Hospital, Ellis Medicine, Glens Falls Hospital, Moses Luddington Hospital, Nathan Littauer Hospital, St. Mary's Healthcare (Amsterdam), Saratoga Hospital, Adirondack Health Institute, Community Health Center, High Peaks Hospice, Saratoga County Office for the Aging, and Washington County CARES.

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Counties Served:

Fulton, Montgomery, Herkimer, Schoharie, Saratoga, Hamilton, and Warren Counties