The New York State Department of Health has awarded a $376,000 grant to Niagara Falls Memorial Medical Center to support the launch of an innovative program to support family members caring for Medicaid beneficiaries at home and in the community.
The program, called "Building Bridges to Home and Community Care," will restructure the hospital discharge process to ensure better post-hospital care and reduce hospital readmissions and nursing home stays, thereby generating more than $2.3 million in Medicaid savings between now and September 2015.
The "bridges" will be built by a specially trained team of professionals - including discharge planners, social workers and resource coordinators - from Memorial Medical Center and Horizon Health Services.
"This team will develop unified care transition plans, provide direct education and support, and connect caregivers to medical, mental health and medication management assistance," said Memorial Chief Operating Officer Sheila K. Kee, who will oversee the program.
"Horizon is excited to partner with Niagara Falls Memorial on this important initiative," said Horizon Health Services President and CEO Anne D. Constantino.
"Team members and home care personnel will be the foot soldiers for this program," Kee said. "In addition to working closely with patients and caregivers, we will incorporate support mechanisms such as a telephone hotline, community resource guide and safe housing registry."
Memorial President and CEO Joseph A. Ruffolo said the problems encountered by caregivers after a patient is discharged from the hospital rank among the leading causes of hospital readmissions and nursing home placements.
"A discharge can be an abrupt and unsettling event for family members who aren't prepared for the challenges of providing home care," he said. "Sheila has designed a program that will enable patients and caregivers to successfully make the transition from hospital to home by providing the tools and support needed to meet those challenges. It's a credit to her efforts that the state, in a very competitive process, has awarded funding for it."
Ruffolo noted the new program will be a collaborative effort, as are the medical center's "Health Home," "Health Insurance Navigator" and "Healthy Moms Healthy Babies" programs. A "Building Bridges to Home and Community Care" conference will be held this fall for more than 50 community-based agencies to discuss the elements and benefits of the program and explore additional strategies for at-home safety and wellness.