Not all patients who recover from an acute illness are ready to go home.

“Alternative level of care” patients, such as those who cannot live on their own, might need to go to a post–acute care facility. However, they can face several barriers to being placed in long-term care, including health insurance status, cognitive impairment, mental health, housing options, and limited space in nursing facilities.

NYC Health + Hospitals (NYC H+H), the largest public health care system in the country, is taking steps to change that.

Under the health system’s new “Better Way to Live” program, a team from NYC H+H’s Bellevue Hospital Center takes part in a weekly teleconference with post–acute care facility leaders to review the history, clinical needs, and social concerns of recovering acute-care patients who need to be discharged. When candidates are recommended for transition to one of three post–acute care facilities, the team determines which facility is the best fit and what accommodations need to be made for the patient.

During the pilot program, which began in fall 2016, 62 patients — some of whom were hospitalized up to a year — have been successfully transitioned from Bellevue to one of the post–acute care facilities.

One such patient, “Ms. T,” experienced seven years of homelessness before being admitted to Bellevue; when she recovered, she was found to have significant memory problems and it was challenging to ensure she received appropriate post-discharge care. Through the program, she was transitioned to a memory care unit at one of NYC H+H’s acute-care facilities. As a result, her mental condition improved and she was able to be completely weaned off of antipsychotic medication.

NYC H+H plans to operate the program in all 11 of its hospitals and five post–acute care facilities this year. Once the program has been expanded, it is expected to save the health system more than $3.5 million a year.