Category Archives: Care transitions

Mar 25 2014

Sharing Nursing’s Knowledge: The March 2014 Issue

Have you signed up to receive Sharing Nursing’s Knowledge? The monthly Robert Wood Johnson Foundation (RWJF) e-newsletter will keep you up to date on the work of the Foundation’s nursing programs, and the latest news, research, and trends relating to academic progression, leadership, and other essential nursing issues. Following are some of the stories in the March issue.

Nurses Need Residency Programs Too, Experts Say
Health care experts, including the Institute of Medicine in its report on the future of nursing, tout nurse residency programs as a solution to high turnover among new graduate nurses. Now, more hospitals are finding that these programs reduce turnover, improve quality, and save money. Success stories include Seton Healthcare Family in Austin, Texas, which launched a residency program to help recent nursing school graduates transition into clinical practice. Now, three out of four new graduate nurses make it to the two-year point, and five or six new nurse graduates apply for each vacant position.

Iowa Nurses Build Affordable, Online Nurse Residency Program
Some smaller health care facilities, especially in rural areas, cannot afford to launch nurse residency programs to help new nurses transition into clinical practice. A nursing task force in Iowa has developed an innovative solution: an online nurse residency program that all health care facilities in the state—and potentially across the country—can use for a modest fee. The task force was organized by the Iowa Action Coalition and supported by an RWJF State Implementation Program grant.

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Feb 28 2014

The Role of Community Health Workers in Promoting Health: 'Talk to Me About Anything'

Shreya Kangovi, MD, is an assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine, executive director of the Penn Center for Community Health Workers, and a Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholars program alumna.


“What do you think will help you stay healthy after discharge?”

Mr. Manzi, a soft-spoken man in his early 60s, paused to consider. No one had asked him this question before. He had come to the hospital because of blurry vision and thirst too severe to ignore. The doctors told him that he had severe diabetes and hypertension, and that he needed to adhere to a long list of new medications, tests, and appointments.  

“Not just medical stuff,” Anthony, the community health worker, continued. “Talk to me about anything. Dealing with shut-off notices, housing issues, whatever you think you need to stay healthy.”

Mr. Manzi opened up. He explained that he was originally from Ghana but had been living and working odd jobs in Philadelphia for 20 years as an undocumented immigrant. He had not had a job in six months and twice, his home had gone into foreclosure. Mr. Manzi was uninsured and had not been able to get outpatient care before coming to the hospital.

“I’m willing to do whatever it takes to stay healthy,” he concluded. “But I need to make sure I can pay for all of these medications and a doctor. And I need some help with the foreclosure—I can’t take care of myself if I lose my home.” 

Mr. Manzi’s answers became the basis for his tailored intervention. IMPaCT (Individualized Management for Patient-Centered Targets) is an innovative model of care in which community health workers (CHWs) provide tailored support to help patients achieve individualized goals. Anthony, an IMPaCT CHW, shares socioeconomic background with patients like Mr. Manzi. He and other IMPaCT CHWs are selected for traits such as empathy, active listening, and reliability.  

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Mar 22 2013

Upcoming Webinar: Transitional Care Model for Persons with Serious Mental Illness

On March 27, 2013, Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI) investigators Nancy Hanrahan, RN, PhD, and Phyllis Solomon, PhD, will present a webinar on their research translating a transitional care nursing intervention for people with serious mental illness for patients in public managed care.

The researchers’ Transitional Care Model for Persons with Serious Mental Illness (TCM-SMI) was designed to help psychiatric patients transition from hospitalization back into the community by providing 90 days of intensive hospital-to-home services. The nursing intervention proposed to reduce readmissions and depletion of scare public resources by these patients with complex needs.

The webinar will take place from 12-1 p.m. EST. It is part of a series featuring all of INQRI’s grantee teams focused on translating research into practice.

Register for the webinar.
Learn more about Hanrahan and Solomon’s research.

Nov 23 2012

Human Capital News Roundup: The nurse faculty shortage, discharging homeless patients, “diaper deserts,” and more.

Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:

NJ Spotlight reports on a state Senate committee hearing in New Jersey this week at which legislators heard from health, business and academic leaders about how the New Jersey Nursing Initiative has made progress in addressing the state’s staggering 10.5 percent nursing faculty vacancy rate. Among those testifying was John Lumpkin, RWJF senior vice president and director of the Health Care Group. Read more about the hearing.

A study by RWJF Health & Society Scholars alumnus Haslyn Hunte, PhD, MPH, and colleagues find that Blacks who feel discriminated against or mistreated are more likely to abuse alcohol and illegal drugs, Medical XPress reports.

Kelly Doran, MD, an RWJF/U.S. Department of Veterans Affairs Clinical Scholar, wrote a blog for the Huffington Post about why “Hospitals Should Never Discharge Homeless Patients to the Streets.” Hospital care teams often discharge patients “to home” without asking or thinking about their housing situations, perpetuating their cycle of homelessness by sending them back to the streets instead of supportive housing, she writes. Fierce Healthcare also reported on Doran’s post.

Brendan Nyhan, PhD, an alumnus of the RWJF Scholars in Health Policy Research program, gave comments to the Daily Beast about political reporting and predicting election results.

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Oct 4 2012

Human Capital News Roundup: Care transitions, "chemobrain," medical research funding, and more.

Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:

RWJF Clinical Scholars alumnus Eric Coleman, MD, is one of 23 MacArthur Fellows for 2012—the so-called "genius award," the MacArthur Foundation announced. Coleman is director of the Care Transitions Program, the New York Times reports, which has helped hundreds of hospitals and community agencies across the country improve communication among patients and health care providers to reduce the likelihood of readmissions.  Read more about his work and award.

Several years ago, RWJF Scholar in Health Policy Research alumnus Harold Pollack, PhD, and his wife “became custodians for his adult brother-in-law, who is intellectually disabled and has various medical problems. Harold has written about this experience before, movingly—and what it’s taught him about the value of programs like Medicaid,” The New Republic reports. “Now he’s decided to put his thoughts on a video.”

The New York Times spoke to Andrea Campbell, PhD, about a study she co-authored that looked at the aftermath of the Supreme Court’s health reform ruling. In upholding the Affordable Care Act, the Court simultaneously bolstered public support for the law and hurt its own reputation with the general public, Campbell found—a combination of outcomes she said put the decision in a "public opinion class by itself." Campbell is an alumna of the Scholars in Health Policy Research program and recipient of an RWJF Investigator Award in Health Policy Research.

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Jul 12 2012

How the Affordable Care Act Would Have Helped My Father

This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act.  Susan B. Hassmiller, PhD, RN, FAAN, is the Robert Wood Johnson Foundation Senior Adviser for Nursing and Director, Future of Nursing: Campaign for Action. This post also appears on Off the Charts, the blog of the American Journal of Nursing.


When I heard that the Supreme Court upheld the Affordable Care Act, I immediately thought of my father.  He suffered mightily at the end of his life. Plagued with multiple chronic illnesses, he spent his last year in and out of hospitals.  He received good hospital care, but his health deteriorated every time he left. He simply couldn’t keep track of a growing list of prescriptions, tests and doctor visits.  My father accidentally skipped antibiotics, which led to infections, which landed him back in the hospital. He accidentally skipped blood tests, which landed him back in the hospital. It seemed that every time he came home, he’d land back in the hospital. I lived thousands of miles away and couldn’t be the advocate that he needed.


What he needed was transitional care – he needed a nurse to meet with him during a hospitalization to devise a plan for managing chronic illnesses and then follow him into his home setting. He needed a nurse to identify reasons for his instability, design a care plan that addressed them and coordinate various care providers and services. He needed a nurse to check up on him at home.  Transitional care would have eased his suffering and enabled him to live better.

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