Special Projects Fund

Grantee Name

Home Aide Service of Eastern New York, Inc., (dba Eddy Visiting Nurse Association)

Funding Area

Special Projects Fund

Publication Date

August 2013

Grant Amount


Grant Date:

November 24, 2010 – May 22, 2013

Seventy-five percent of the nation’s health care spending is spent on patients with chronic conditions.

Providing care for these patients at home can reduce these costs, but has proven to be a logistical challenge. One model of care, developed in Arkansas, shows promise—Baptist Health’s Home-based Chronic Care Model improved outcomes and quality of care while cutting back on costs and staff member turnover. The Home-based Chronic Care model focuses on patient empowerment, theory-based behavioral interventions, and care coordination, and incorporates telemedicine and depression screening into current models of home-based care. The Eddy Visiting Center is the largest home health care agency in the greater Capital Region. Serving more than 5,000 patients in both urban and rural communities, it is well positioned to pilot this model of care in New York State.

In November 2010, the New York Health Foundation (NYHealth) awarded a grant to the Eddy Visiting Nurse Association to implement the Baptist Health Home-based Chronic Care Model and evaluate its capacity to transform home health care in New York State.

Outcomes and Lessons Learned

  • Emergency department visits were reduced by 26%;
  • Hospitalizations were reduced by 10%, even though patient acuity/case mix increased by 10%;
  • Oral medication management increased by 12.4%;
  • All patients were screened for depression, and 95% of those who screened positive received an appropriate intervention;
  • A total of 352 staff members were certified in chronic care management; 78% of staff members reported that they were satisfied with the Baptist Home-based Care model.
  • Eighty-seven percent of patients were satisfied with the care they received; and
  • The evaluation is in its final stages, and is being conducted by William Foley, Ph.D., Clinical Associate Professor, Decision Sciences and Engineering Systems, Rensselaer Polytechnic Institute.

NYHealth funding was targeted toward the addition of clinical specialists who focus on chronically ill patients, including those in need of cardiac, diabetes, and respiratory care. Additional start-up funding for this program was provided by The Eddy Foundation, including support for chronic care certification of all existing staff members and project evaluation.