Special Projects Fund

Project Title

Transforming Home-Based Chronic Care Management

Grant Amount


Priority Area

Special Projects Fund

Date Awarded

November 24, 2010


Capital Region






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.

This grant allows the Eddy to hire two additional clinical nurse specialists in the areas of diabetes and pulmonary care. These specialists are incorporating evidence-based care plans into an electronic medical record; training frontline home care workers; monitoring and improving agency-wide quality indicators; discussing care plan recommendations with physicians; and serving as consultants in the care of the most complex patients. Current clinicians and nurse practitioners are being trained and will receive certification in chronic care management.