2016 New York Laws
PBH - Public Health
Article 28 - (Public Health) HOSPITALS
2805-X - 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.
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.