Improving transitions in care: Community Visiting Nurse Association's Collaborative Approach to Reach Patient Empowerment

The Foundation's program, New Jersey Health Initiatives, was designed to support projects in New Jersey that develop new approaches to resolving the state's health care needs, focusing on the Foundation's goal areas.This project will serve patients who live in either Somerset or Middlesex Counties. Utilizing an Advanced Practice Nurse (APN) in a shared position among eight community providers, the collaborative strives to break down the barriers to care and ability for patients to self manage their chronic illnesses and health needs. Interventions include APN contact upon admission, throughout hospital stay and before and after any transition among providers, customized educational workbooks, enhancement of practitioners skills in caring for chronically ill patients and in understanding the transition process, enhanced communication between the APN, the treating and community physician, universal tools such as risk assessments, transfer summaries, medication reconciliation, readiness to learn, transition surveys and patient centered care plans. The program will follow 1,200 patients from admission to Somerset Medical Center through the completion of services from any of the providers up to 1 year. In addition to the traditional services of LTC, sub acutes, assisted living, homecare and hospice, patients will be encouraged to participate in long-term support through Community VNA's care management program or Somerset Medical Center's outpatient Diabetic services.

Grant Details

Amount Awarded $300,000.00

Awarded on: 6/28/2011

Time frame: 7/1/2011 - 6/30/2013

Grant Number: 69122