Iroquois Healthcare>Hospital-Home Care Collaboration

HOSPITAL-HOME CARE COLLABORATION

The Iroquois Healthcare Association (IHA), in partnership with the Home Care Association of New York State Education & Research (HCA E&R) and the Healthcare Association of New York State (HANYS), led a statewide Hospital–Home Care Collaboration Program through funding from the Mother Cabrini Health Foundation.

This initiative was designed to strengthen coordination between hospitals and home care providers across the care continuum—from pre-acute care to post-discharge recovery and long-term support. The program focused on improving patient outcomes, reducing avoidable hospitalizations, and enhancing system-wide efficiency through stronger cross-setting collaboration.

 

Program Overview

Through this initiative, IHA and its partners developed and delivered a series of educational webinars, collaboration models, and technical assistance resources to support providers across New York State. Key areas of focus included:
  • Strengthening pre-acute and post-acute care coordination
  • Reducing hospital admissions and readmissions
  • Supporting patient recovery in home-based settings
  • Advancing integrated care across hospitals, home care, and community partners

The program highlighted real-world collaboration models that could be replicated and adapted by healthcare organizations statewide.


Key Program Components

Impact & Outcomes

This initiative supported healthcare providers across New York State by:
  • Advancing scalable models for hospital–home care collaboration
  • Enhancing care transitions and patient outcomes
  • Promoting interdisciplinary and cross-sector partnerships
  • Strengthening system capacity during critical periods, including the COVID-19 pandemic
  • Providing actionable frameworks for workforce, behavioral health, and aging services integration

 


Reports

As part of the program, several key reports were developed to support ongoing collaboration efforts:
These resources continue to serve as practical guides for healthcare organizations seeking to implement or expand collaborative care models.

 


Recorded Webinars

As part of the initiative, a comprehensive webinar series showcased real-world hospital–home care collaboration models, offering practical insights, replicable strategies, and lessons learned from providers across New York State and beyond.
 
 

Featured Webinars

A Blueprint for a Collaboration Model – Rhode Island Nurses Institute Middle College Charter School
November 2022
Explores an innovative early pipeline model for nursing education beginning in middle school, designed to strengthen long-term workforce development.
→ View Recording | View Presentation | View Blueprint Narrative

 

A Blueprint for a Collaboration Model – Early College for Aspiring Healthcare Workers
December 2022
Highlights a partnership between Oswego Health, Fulton City School District, and Cayuga Community College to create early college pathways into healthcare careers.
→ View Recording | View Blueprint Narrative

 

Models of Hospital–Home Care Electronic Health Record Integration
May 2022
Provides strategies and real-world examples of EHR integration between hospital systems and home care providers.
→ View Recording | View Presentation

 

Collaboration of Care for Patients with Mental Illness Across the Health System
April 2022
Demonstrates integrated care approaches across hospital, outpatient, and home care settings, with a focus on telehealth.
→ View Recording | View Presentation

 

Innovations in Care and Management through Hospital–Home Care Collaboration
March 2022
Explores cutting-edge collaborative models advancing patient care and population health outcomes.
→ View Recording | View Presentation

 

A Blueprint of a Collaboration Model (M.S. Hall & Associates)
February 2022
Introduces a strategic “how-to” framework using business model design for building collaborative programs.
→ View Recording | View Presentation | View MS Hall – UR Collaboration Business Model | View MS Hall – UR Hospital and Home Care Collaboration Blueprint Narrative

 

Emergency Department Diversion & Inpatient Admissions Collaborative Program
February 2022
Focuses on reducing avoidable ED visits and hospitalizations through home-based interventions.
→ View Recording | View Presentation

 

Acute Care at Home Model Developed During COVID-19 Surge
September 2021
Examines a patient-centered model designed to manage hospital capacity during pandemic surges.
→ View Recording | View Presentation

 

Point of Dispensing Collaborative to Reach Underserved Populations
September 2021
Highlights mobile vaccination efforts and community partnerships addressing health disparities.
→ View Recording | View Presentation

 

Home Asthma Management Collaborative
October 2021
Demonstrates a partnership improving outcomes for pediatric and young adult asthma patients through home-based care.
→ View Recording | View Presentation

 

Complex Care Collaborative
November 2021
Showcases a multi-organization model for managing high-need, complex patient populations.
→ View Recording | View Presentation

 
 
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Additional Resources

General Collaboration Resources

 

Clinical Areas for Collaboration

The following focus areas represent conditions commonly associated with avoidable hospitalizations and opportunities for enhanced collaboration:
Sepsis
Pressure Ulcers
Laws & Policies Governing Collaboration
Telehealth & Collaboration
Person-Centered Care