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
Foundation of University of Medicine & Dentistry of New Jersey
Closed
Implementing systems to manage transitions in care and reduce hospital readmissions.
Foundation of University of Medicine & Dentistry of New Jersey
2011
Closed
Grant Award Amount
$300,000

The I-Care 4 Health Transition project builds upon a successful Department of Medicine project that tested the effectiveness of a transitional care coordinator (APN with case management skills) in improving diabetes outcomes. Four levels of providers will co-manage chronic conditions across the continuum of care. Health literacy interventions will occur during the inpatient stay, with navigation through the healthcare system, and follow with transitional care by advanced practice nurses to prevent 30-day emergency department recidivism. The project is a collaboration among New Jersey Medical School, the Rutgers College of Nursing, and community providers (Visiting Nurse Association of Central NJ and Newark Community Health Center).

Project
I-Care 4 Health Transitions: Improving Care for a Health Transition using a 4-Tiered Approach to Collaboration Across the Continuum
Topics
Grant Recipient
Foundation of University of Medicine & Dentistry of New Jersey
Key Contact
Melissa Scollan-Koliopoulos
Assistant Professor
(973) 972-1728
Counties Served