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
Saint Barnabas Health Care System
Closed
Implementing systems to manage transitions in care and reduce hospital readmissions.
Saint Barnabas Health Care System
2011
Closed
Grant Award Amount
$299,981

The Transition Program at Monmouth Medical Center will serve people age 65 and older with dementia and multiple other chronic conditions a population at high risk for adverse health outcomes, hospital readmission, and mortality. This program consists of eight core components: 1) patient-identified goals and activities; 2) barrier and support resources identification; 3) patient and caregiver education; 4) prescription reconciliation and education; 5) multidisciplinary case conferencing; 6) development of a detailed, patient-specific My Care Plan 7) ‘receiving provider’ notification; and 8) follow-up care and home visits. Expected outcomes include decreased 30-day readmission rates, decreased Emergency Department visits, and cost-effectiveness.

Project
SBHCS Transition Program for the Frail Elderly with Dementia
Topics
Grant Recipient
Key Contact
Allan Tunkel
Chair, Department of Medicine
(732) 923-6540
Counties Served