New Jersey Health Initiatives - A Better State of Health
A Robert Wood Johnson Foundation Program
Implementing systems to manage transitions in care and reduce hospital readmissions.
2011
Cooper Foundation
Closed
Implementing systems to manage transitions in care and reduce hospital readmissions.
Cooper Foundation
2011
Closed
Grant Award Amount
$300,000

To improve care transitions for complex, costly, and high utilizing patients, with a goal of reducing unnecessary hospital readmissions in the City of Camden, trained nurse care coordinators and health coaches will be embedded in local Federally Qualified Health Centers. The care transitions team will also work with hospital-based social workers, hospitalists and discharge planners to coordinate the planning and post-discharge continuity of care. Emphasis will be placed on inter-professional case-conferencing among hospital and clinic care providers.  Project outcomes will ideally reflect a reduction in hospital readmissions, reductions in hospital costs and increased primary care coordination in Camden.

Project
Camden Coalition of Healthcare Providers – Improving Care Transitions for High Needs, High Cost Patients in Camden
Topics
Grant Recipient
Key Contact
Jeffrey Brenner
Executive Director/Medical Director
(609) 876-9549
Counties Served
View All: NJHI: 2011: Transitions in Care