All too often we see patients discharged from the hospital, only to be readmitted days or weeks later for the same condition.  Preventable hospital readmissions are a large and ongoing problem, as is unnecessary Emergency Department use. According to the WNY Community Needs Survey, we have over 113,000 potentially preventable ED admissions per year for our Medicaid population alone.  Of those potentially preventable admissions, COPD, Diabetes, and Cardiac conditions account for 79,674 of them.  What is happening to our patients while they are at home that cause them to decline and require another hospital stay?

The Hospital Home Care Collaborative Solutions project seeks to answer just that.  With its primary focus being to strengthen the transition from a patient’s hospital stay to home, this project incorporates healthcare professionals working in Acute Care, Home Care, Skilled Nursing Facilities, and Community based care.  By addressing potential areas of need across the continuum of care, patients are more likely to receive the appropriate level of care in the fastest time possible, while decreasing the risk of re-hospitalization.  Enhancing Home Care services, decreasing medication errors, increasing the use of Telehealth Technology, and creating better pipelines for community based care are the core tenants this project is built upon.

Home care services are typically provided for patients who may require further strengthening, monitoring, or restorative treatment following a hospital discharge.  However, many do not realize that an acute care stay or ED visit is not necessary to receive these services.  Home Care can begin with a referral from a primary care physician within the community.  Currently, more streamlined processes are being put in place to arrange Home Care services or short stays in a Skilled Nursing Facility from the ED, so a patient may avoid an Observation or In-Patient hospitalization and instead be treated within the comforts of their own home.  Doing so reduces the risk of hospital acquired infections, immobility, and delirium.

Education is also a key part to the Hospital Home Care Collaborative Solutions Project.  Ensuring our patients have the information they need to make good medical choices is a goal we are striving to meet at every access point in healthcare.  Educating patients and families about specific diagnoses including what the signs and symptoms of an exacerbation are, what medications and diets they should be following to avoid complications, and who they can turn to if they do need medical assistance, will enable healthier lifestyles and decrease hospitalizations of those with chronic conditions.

Whether it is in the emergency room, at the bedside in the hospital, in the living room of their home, or in the primary care office, we are striving to create a more cohesive, integrated healthcare system.  Through collaboration and education, patients will experience a more unified, patient centered healthcare experience that will be of good quality to ensure the best possible outcome possible for each and every patient.

If you have any further comments or questions regarding this project, please feel free to contact Saralin Tiedeman, Project Manager at (716)898-6425, or e-mail at


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The Erie County Medical Center Corporation (ECMCC) is the parent organization of Millennium Collaborative Care

Millennium Collaborative Care

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