Hospital-home care-physician collaboration program

§ 2805-x. Hospital-home care-physician collaboration program. 1. The
purpose of this section shall be to facilitate innovation in hospital,
home care agency and physician collaboration in meeting the community's
health care needs. It shall provide a framework to support voluntary
initiatives in collaboration to improve patient care access and
management, patient health outcomes, cost-effectiveness in the use of
health care services and community population health. Such collaborative
initiatives may also include payors, skilled nursing facilities and
other interdisciplinary providers, practitioners and service entities.

2. For purposes of this section:

(a) "Hospital" shall include a general hospital as defined in this
article or other inpatient facility for rehabilitation or specialty care
within the definition of hospital in this article.

(b) "Home care agency" shall mean a certified home health agency, long
term home health care program or licensed home care services agency as
defined in article thirty-six of this chapter.

(c) "Payor" shall mean a health plan approved pursuant to article
forty-four of this chapter, or article thirty-two or forty-three of the
insurance law.

(d) "Practitioner" shall mean any of the health, mental health or
health related professions licensed pursuant to title eight of the
education law.

3. The commissioner is authorized to provide financing including, but
not limited to, grants or positive adjustments in medical assistance
rates or premium payments, to the extent of funds available and
allocated or appropriated therefor, including funds provided to the
state through federal waivers, funds made available through state
appropriations and/or funding through section twenty-eight hundred
seven-v of this article, as well as waivers of regulations under title
ten of the New York codes, rules and regulations, to support the
voluntary initiatives and objectives of this section.

4. Hospital-home care-physician collaborative initiatives under this
section may include, but shall not be limited to:

(a) Hospital-home care-physician integration initiatives, including
but not limited to:

(i) transitions in care initiatives to help effectively transition
patients to post-acute care at home, coordinate follow-up care and
address issues critical to care plan success and readmission avoidance;

(ii) clinical pathways for specified conditions, guiding patients'
progress and outcome goals, as well as effective health services use;

(iii) application of telehealth/telemedicine services in monitoring
and managing patient conditions, and promoting self-care/management,
improved outcomes and effective services use;

(iv) facilitation of physician house calls to homebound patients
and/or to patients for whom such home visits are determined necessary
and effective for patient care management;

(v) additional models for prevention of avoidable hospital
readmissions and emergency room visits;

(vi) health home development;

(vii) development and demonstration of new models of integrated or
collaborative care and care management not otherwise achievable through
existing models; and

(viii) bundled payment demonstrations for hospital-to-post-acute-care
for specified conditions or categories of conditions, in particular,
conditions predisposed to high prevalence of readmission, including
those currently subject to federal/state penalty, and other discharges
with extensive post-acute needs;

(b) Recruitment, training and retention of hospital/home care direct
care staff and physicians, in geographic or clinical areas of
demonstrated need. Such initiatives may include, but are not limited to,
the following activities:

(i) outreach and public education about the need and value of service
in health occupations;

(ii) training/continuing education and regulatory facilitation for
cross-training to maximize flexibility in the utilization of staff,
including:

(A) training of hospital nurses in home care;

(B) dual certified nurse aide/home health aide certification; and

(C) dual personal care aide/HHA certification;

(iii) salary/benefit enhancement;

(iv) career ladder development; and

(v) other incentives to practice in shortage areas; and

(c) Hospital - home care - physician collaboratives for the care and
management of special needs, high-risk and high-cost patients, including
but not limited to best practices, and training and education of direct
care practitioners and service employees.

(d) Collaborative programs to address disparities in health care
access or treatment, and/or conditions of higher prevalence, in certain
populations, where such collaborative programs could provide and manage
services in a more effective, person-centered and cost-efficient manner
for reduction or elimination of such disparities.

(i) Such programs may target one or more disparate conditions, or
areas of under-service, evidenced in defined populations, including but
not be limited to:

(A) cardiovascular disease;

(B) hypertension;

(C) diabetes;

(D) chronic kidney disease;

(E) obesity;

(F) asthma;

(G) sickle cell disease;

(H) sepsis;

(I) lupus;

(J) breast, lung, prostate and colorectal cancers;

(K) geographic shortage of primary care, prenatal/obstetric care,
specialty medical care, home health care, or culturally and
linguistically compatible care;

(L) alcohol, tobacco, or substance abuse;

(M) post-traumatic stress disorder and other conditions more prevalent
among veterans of the United States military services;

(N) attracting members of minority populations to the field and
practice of medicine; and

(O) such other areas approved by the commissioner.

(ii) Collaborative hospital-home care-physician, and as applicable
additional partner, models may include under such disparities programs:

(A) service planning and design;

(B) recruitment of specialty personnel and/or specialty training of
professionals or other direct care personnel (including physicians, home
care and hospital staffs), patients and informal caregivers;

(C) continuing medical education and clinical training for physicians,
follow-up evaluations, and supporting educational materials;

(D) use of evidenced-based approaches and/or best practices to
treatment;

(E) reimbursement of uncovered services;

(F) bundled or other integrated payment methods to support the
necessary, coordinated and cost-effective services;

(G) regulatory waivers to facilitate flexibility in provider
collaboration and person-centered care;

(H) patient/family peer support and education;

(I) data collection, research and evaluation of efficacy; and/or

(J) other components or innovations satisfactory to the commissioner.

(iii) Nothing contained in this paragraph shall prevent a physician,
physicians group, home care agency, or hospital from individually
applying for said grant.

(iv) The commissioner shall consult with physicians, home care
agencies, hospitals, consumers, statewide associations representative of
such participants, and other experts in health care disparities, in
developing an application process for grant funding or rate adjustment,
and for request of state regulatory waivers, to facilitate
implementation of disparities programs under this paragraph.

5. Hospitals and home care agencies which are provided financing or
waivers pursuant to this section shall report to the commissioner on the
patient, service and cost experiences pursuant to this section,
including the extent to which the project goals are achieved. The
commissioner shall compile and make such reports available on the
department's website.