NYC Health + Hospitals develops system to manage hard-to-discharge patients

NYC Health + Hospitals launched a pilot program designed to improve the quality of life of long-term hospital patients who are difficult to discharge into post-acute care settings. Through the program, which could save hospitals millions in costly and unnecessary hospital stays, patients transition out of the hospital and into post-acute settings that are better suited to provide the care they need.

The "Better Way to Live" program combines hospital and post-acute care providers to develop a new transition path, targeted interventions and services for "alternate level of care" patients, or patients who are no longer acutely ill but cannot live on their own due to medical, mental health and social challenges.

The pilot has already successfully transitioned more than 60 ALC patients — some who were hospitalized for months or even a year — into long-term care beds in the public health system's post-acute care facilities. Once NYC Health + Hospitals expands the pilot across the whole system, the program is expected to save the organization more than $3.5 million a year.

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