Glens Falls Hospital and Fort Hudson Health System have developed a new model of care for patients which will more effectively integrate acute and post-acute services. The jointly developed program, known as the Partnership for Better Health, targets patients at Glens Falls Hospital who require short term rehabilitation or home health care and have risk factors which increases their chance of future hospitalizations.
Preventing avoidable hospitalizations is the primary goal of this partnership. Hospitalized patients who have one or more risk factors, such as chronic respiratory or cardiac conditions, will be offered the option of participating in the program through a preferred provider relationship with Fort Hudson. Patients always have the right to choose their healthcare options. If patients decide to participate in this new program, they will have access to the short term rehab or home health care as well as transitional support to home through the Fort Hudson Care Management program.
“Creating a vertically integrated system of care delivery for at-risk patients will improve their outcomes and prevent unnecessary hospital or emergency department visits,” according to Dianne Shugrue, President and CEO of Glens Falls Hospital. “Our partnership with Fort Hudson will offer a preferred path with a quality provider for post-acute care; the only one which offers such a comprehensive array of services.”
“Fort Hudson and Glens Falls Hospital share a common goal of improving care through collaboration” says Andy Cruikshank, CEO of Fort Hudson Health System. “This program brings together the expertise of both providers, with an over-arching support from our Care Management program; bridging all levels of care.”
As patients move from acute to post-acute to home, care managers will meet with the patients at multiple points and coordinate additional services or provide a transition to an existing care management program through their primary care physician or other existing program.
The Partnership for Better Health program is partially supported by Adirondack Health Institute and the state-wide Delivery System Reform Incentive Program (DSRIP). Fort Hudson and Glens Falls Hospital submitted a joint application which highlighted the need for closer collaboration to create a sustainable model of integration between providers.
Fort Hudson Health System is a non-profit multilevel senior health care and housing provider located in Fort Edward NY. Its programs include skilled nursing; short term rehabilitation; specialized dementia care programs; two adult day care programs; licensed and certified home care; care management; and senior retirement living.