§ 2805-x. Hospital-home care-physician collaboration program. 1. The\npurpose of this section shall be to facilitate innovation in hospital,\nhome care agency and physician collaboration in meeting the community's\nhealth care needs. It shall provide a framework to support voluntary\ninitiatives in collaboration to improve patient care access and\nmanagement, patient health outcomes, cost-effectiveness in the use of\nhealth care services and community population health. Such collaborative\ninitiatives may also include payors, skilled nursing facilities and\nother interdisciplinary providers, practitioners and service entities.\n 2. For purposes of this section:\n (a) "Hospital" shall include a general hospital as defined in this\narticle or other inpatient facility for rehabilitation or specialty care\nwithin the definition of hospital in this article.\n (b) "Home care agency" shall mean a certified home health agency, long\nterm home health care program or licensed home care services agency as\ndefined in article thirty-six of this chapter.\n (c) "Payor" shall mean a health plan approved pursuant to article\nforty-four of this chapter, or article thirty-two or forty-three of the\ninsurance law.\n (d) "Practitioner" shall mean any of the health, mental health or\nhealth related professions licensed pursuant to title eight of the\neducation law.\n 3. The commissioner is authorized to provide financing including, but\nnot limited to, grants or positive adjustments in medical assistance\nrates or premium payments, to the extent of funds available and\nallocated or appropriated therefor, including funds provided to the\nstate through federal waivers, funds made available through state\nappropriations and/or funding through section twenty-eight hundred\nseven-v of this article, as well as waivers of regulations under title\nten of the New York codes, rules and regulations, to support the\nvoluntary initiatives and objectives of this section.\n 4. Hospital-home care-physician collaborative initiatives under this\nsection may include, but shall not be limited to:\n (a) Hospital-home care-physician integration initiatives, including\nbut not limited to:\n (i) transitions in care initiatives to help effectively transition\npatients to post-acute care at home, coordinate follow-up care and\naddress issues critical to care plan success and readmission avoidance;\n (ii) clinical pathways for specified conditions, guiding patients'\nprogress and outcome goals, as well as effective health services use;\n (iii) application of telehealth/telemedicine services in monitoring\nand managing patient conditions, and promoting self-care/management,\nimproved outcomes and effective services use;\n (iv) facilitation of physician house calls to homebound patients\nand/or to patients for whom such home visits are determined necessary\nand effective for patient care management;\n (v) additional models for prevention of avoidable hospital\nreadmissions and emergency room visits;\n (vi) health home development;\n (vii) development and demonstration of new models of integrated or\ncollaborative care and care management not otherwise achievable through\nexisting models; and\n (viii) bundled payment demonstrations for hospital-to-post-acute-care\nfor specified conditions or categories of conditions, in particular,\nconditions predisposed to high prevalence of readmission, including\nthose currently subject to federal/state penalty, and other discharges\nwith extensive post-acute needs;\n (b) Recruitment, training and retention of hospital/home care direct\ncare staff and physicians, in geographic or clinical areas of\ndemonstrated need. Such initiatives may include, but are not limited to,\nthe following activities:\n (i) outreach and public education about the need and value of service\nin health occupations;\n (ii) training/continuing education and regulatory facilitation for\ncross-training to maximize flexibility in the utilization of s
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