ONONDAGA COUNTY, NEW YORK – For the past 18 months, Crouse Hospital and St. Joseph’s Home Care Services have been participating in a quality improvement collaborative focused on transitions of care for frail elders. The collaborative was supported and sponsored by the Community Health Foundation of Western and Central New York.

The purpose of the collaborative was to stimulate change in practice and care delivery systems to improve transitions for frail elders as they move from one health care setting or practitioner to another as their condition and level of care needs change. In this instance the transition of care focused on the hospital to the home.

“During transitions of care between health settings, information shared with patients and their caregivers is often confusing or missing critical information, but with better management of these transitions comes improved continuity, a reduction in error and delay and an increase in patient control of health decisions,” said Ann F. Monroe, president, Community Health Foundation of Western and Central New York.

The Crouse Hospital and St. Joseph’s Home Care Services project focused on supporting patients with congestive heart failure as well as atrial fibrillation patients in their transition from hospital to home care through a transition coach. As a result of utilizing a transition coach, hospital readmissions among these patients were reduced from 9.7% to 3.3% and post-hospital medical follow-up procedures were also changed. The transition coach has become the standard of care for Crouse Hospital and atrial fibrillation patients.

“The goals of our program were to reduce avoidable emergency hospital visits for these patients and to improve patient satisfaction, reduce incidents related to medications and assist patients in maintaining their overall quality of life,” said Christy Bond, Director of Senior Centered Care, Crouse Hospital. “We believe that by utilizing a transition coach these goals have been met and we will continue our efforts to improve transitions of care for our elderly patients from the hospital to home.”


About the Community Health Foundation of Western and Central New York: The Community Health Foundation of Western and Central New York is an independent private foundation. It invests in, and partners with, organizations and communities in innovative ways to improve health and healthcare for the vulnerable and underserved. The Foundation’s Board of Trustees has selected frail elders and children from communities of poverty as targeted populations for health improvements over the next several years. The Foundation is based in Buffalo and has a second office in Syracuse. For more information, please visit chfwcny.org.