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United Hospital Fund of New York

  • Project Title: Promoting Patient-Centered Discharge Planning for Post-Acute Care Settings
  • Priority Area: Empowering Health Care Consumers
  • Grant Amount: $219,606
  • Date Awarded: October 2, 2017
  • Region: Statewide
  • Website:
  • Grant Status: In Progress


Post-acute care, including inpatient rehabilitation facilities, nursing homes, home health agencies, and long-term care hospitals, is a critical and growing component of the health care system. Although there have been recent reforms to smooth the transition of patients discharged from hospitals to post-acute facilities and improve continuity of care, the system is not functioning as well as it should. Current hospital discharge protocols often overlook patient preferences and limitations, and the rush to discharge can lead to poor choices with significant consequences. Helping patients and their families choose the right setting at the right time could improve outcomes and lower costs. In 2017, NYSHealth awarded the United Hospital Fund of New York (UHF) a grant to improve the ability of patients and family caregivers to make informed decisions about post-acute care settings.

Under this grant, UHF will examine patient and family caregiver experiences, including opportunities for better communication and information-sharing about post-acute care options. UHF will also study how hospital staff currently involve patients and families and share information to support their post-acute care choices. Discussion groups will be held with patients and family caregivers, hospital discharge teams, nursing home staff, and other key stakeholders to determine what type of information is most helpful and how to improve the discharge planning process for patients. UHF will also convene stakeholders to examine innovations, processes, and models happening in other states and assess their potential for implementation in New York State. Based on its findings, UHF will produce and share a report with specific recommendations and an action plan for improving current practices to create greater transparency and support for patients and caregivers in post-acute care decision-making.