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RWJ Hamilton Receives $300K Grant to Reduce Hospital Readmission Rates
Partnership with Jewish Family & Children’s Services Creates Mercer Care Transition Program
The goal is to improve the quality of life for our patients and to help them become more engaged in the management of their own healthcare,” said Joyce Schwarz, Vice President of Quality.
Date: 8/3/2011

Robert Wood Johnson University Hospital Hamilton, a leader in community healthcare, has partnered with Jewish Family and Children’s Services of Greater Mercer County (JFCS) to launch a program aimed at reducing the number of patients who return to the hospital due to difficulty managing chronic conditions.

The Mercer Care Transition Program (MCT) will focus on 350 patients who are at least 60 years old and suffer from congestive heart failure and/or diabetes and at least one other chronic condition, according to Joyce Schwarz, vice president of Quality at RWJ Hamilton and the project director.

The program, which will include patients who have been hospitalized two or more times, is part of a statewide initiative funded through a grant from the Robert Wood Johnson Foundation (no relation to the hospital) through its New Jersey Health Initiatives Program. The two-year, $300,000 grant to RWJ Hamilton for its MCT program is one of nine projects funded under the NJHI 2011: Transitions in Care program, all of which present innovative strategies and collaborations to address the needs of individuals transitioning to various levels of care after hospitalization.

“Controlling readmission rates is a critical issue for all hospitals as we work to improve the health and wellbeing of our community,” said Skip Cimino, president and CEO of RWJ Hamilton. “As we move forward with healthcare reform health plans are less likely to reimburse hospitals for these return visits.”

At the center of the RWJ Hamilton/JFCS program will be a Transition Coach to work with patients who fit the medical and social criteria. The coach, supervised by Judy Millner, JFCS Secure@Home Program Director, will work with patients for four weeks after discharge ensuring they receive the proper education and support. The ability to keep appointments with physicians, follow doctor instructions for follow up care, and comply with medications helps to prevent return visits to the hospital.

“The goal is to improve the quality of life for our patients and to help them become more engaged in the management of their own healthcare,” said Schwarz. “We believe our patients can learn those skills from the coach so that they can navigate the complex healthcare system we have in this country. Ultimately, less time spent in the hospital is better for the patient and their caregivers.”

The Transition Coach and the patient will work together to develop a plan of care which will assist the patient in self-managing their care after discharge. MCT will include one hospital visit, one home visit and three follow-up phone calls.

By partnering with JFCS, RWJ Hamilton will work with a community-based organization with 75 years of experience providing a wide range of social services across the age continuum. With three comprehensive non-sectarian senior programs serving more than 1,600 residents annually, JCFS has extensive experience providing programs and services to older adults in the community, said project co-director Judith Millner of JCFS.

“We’re excited to be teaming up with a hospital that has such a great reputation for providing excellent care to their patients,” said Millner. “Our experience providing home and community based services is focused on avoiding the devastating impact rehospitalizations have on quality of life for both patients and caregivers.”

Hospital readmission rates have been a focal point of healthcare reform. Across the nation, about 20 percent of hospitalized Medicare patients are readmitted within 30 days at a cost of $17 billion a year, according to a 2009 study published in the New England Journal of Medicine.

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