“During a recent MAX (Medicaid Accelerated eXchange) Series workshop, seamless care transition was identified as a crucial component of reducing preventable Emergency Department visits,” Gouverneur Hospital CEO David Bender said in a news release. “This funding has helped us put in place a new, customizable transition of care model and support that ensures patients remain engaged in their follow-up care, thereby avoiding preventable Emergency Department visits and hospitalizations.”

In the new position, Latta connects patients with a primary care provider or a representative who assists in securing health insurance. Some patients may feel they don’t have enough support in their home or community, and Latta can identify whether they meet the criteria for home health services. Other patients may receive a referral to Health Home where they will become established with a care manager who will assist with tjings such as transportation, prescription cost, housing, childcare, and keeping track of medical appointments.

“As patient navigator, I work one-on-one with patients who may have difficulty navigating the health system,” Latta said in a prepared statement from SLHS. “Those individuals often have a complex medical history, are high utilizers of our Emergency Department, or are frequent readmits to inpatient services. The Care Manager and I educate patients about their disease, recommended treatment, and how to manage potential side effects. The goal is to empower patients and caregivers to take a lead role in their care, and to connect them with the appropriate resources.”

The funding Gouverneur Hospital received through AHI PPS was part of a $250,000 award made to partnering organizations in the St. Lawrence County region to undertake innovative and transformative health care projects.