Expanding Health Care Coverage

Project Title

Transitioning Elderly Patients from Hospital to Home

Grant Amount


Priority Area

Expanding Health Care Coverage

Date Awarded

September 23, 2008


Capital Region

North Country






In 2007, 18.5% of Glens Falls Hospital’s Medicare patients were readmitted to the hospital within 30 days of a hospital admission, compared to the national average of 15%–21% and the statewide average of 12.5%–15%. These acute care readmissions are costly, often indicate a lack of care coordination, and threaten the financial viability of acute care institutions, especially under the provisions of Federal health reform. Hudson Headwaters Health Network (HHHN) and the Glens Falls Hospital proposed a collaborative approach to reduce hospital readmission rates among the Medicare population. Analyzing Medicare admissions from 2006, they discovered that 1,353 patients were readmitted within 30 days of a prior admission, representing 2,429 admissions. The resulting analysis indicated that 40% of the patients with specific medical conditions accounted for 80% of the admissions (542 patients). HHHN and Glens Falls Hospital focused on developing a program that targeted this population and more directly addressed patients’ needs. A second NYHealth grant supported implementation and evaluation of this program.

Hudson Headwaters Health Network (HHHN) and Glen Falls Hospital will test an evidence-based discharge planning intervention to reduce hospital readmissions among Medicare beneficiaries (ages 65 and older) at high-risk for readmission.

Using a methodology developed under their previous planning grant, HHHN and Glens Falls Hospital will screen Medicare patients admitted to Glen Falls Hospital based on age, diagnostic condition at discharge, primary care physician and geographic residence in order to identify persons at risk for readmission. Patients meeting the criteria are assigned to an intervention or control group. The intervention, which combines intensive discharge planning with transition supports to the home environment, is closely modeled after tested studies by the University of Colorado and Boston University School of Medicine. Transition coaches will provide comprehensive services including patient assessment, education, medication management, coordination of follow-up visits and coordination of patients’ personal health records.