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
Princeton HealthCare System
Closed
Implementing systems to manage transitions in care and reduce hospital readmissions.
Princeton HealthCare System
2011
Closed
Grant Award Amount
$300,000

This project will address the transitional care needs of 6,600 recently hospitalized frail elderly patients over 70 years old coping with multiple chronic and acute morbidities during 60 day episodes of care in Central New Jersey. The project’s three-tiered approach is designed to improve integration and information exchange during care transitions as follows: 1) Consulting with and training partners will strengthen transitional communications; 2) The Navigation Program will support patient transitions to the home, and 3) A comprehensive patient registry will improve and streamline electronic communications among partners.

Project
Partnership for PIECE (Patient-Centered Integrated Elder Care and Empowerment)
Topics
Grant Recipient
Key Contact
Kathleen Seneca
Clinical Nurse Leader
(609) 430-7115
Counties Served
View All: NJHI: 2011: Transitions in Care