Improving transitions in care: Matheny Medical and Educational Center's project for developmental disabilities and medically complex conditions
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.The Matheny School and Hospital will develop, with the cooperation of its acute care partners, a model to improve transitions to and from acute care hospitals for persons with multiple chronic conditions associated with developmental conditions such as cerebral palsy, spina bifida, Lesch-Nyhan disease and autism spectrum disorders. Morristown Memorial Hospital and the Robert Wood Johnson University Hospital have agreed to partner with them in this work. The project will be informed largely by the Transitional Care Model tested and refined by Naylor and colleagues at the University of Pennsylvania. The project will serve 55 patients and will combine, refine, expand, and formalize strategies that Matheny has been testing in recent years, including the use of a nurse specifically dedicated to ensuring a smooth and effective transition among care settings and the transmittal of important information about patient care needs via a "mini-medical record," dubbed the "Transition Medical Record." The project also will provide in-service training to acute care hospital staff regarding issues in the health care transition for this challenging population. They will incorporate similar training into the experience provided to medical students and nursing students who visit or rotate through the facility and will conduct Grand Rounds presentations at the partner hospitals and possibly other acute care hospitals near the end of the project's funded term. The success of the project will be evidenced by a reduction in hospital re-admissions, emergency room visits, and improved satisfaction of patients and caretakers with regard to the post-hospital transition.
Amount Awarded $300,000.00
Awarded on: 7/1/2011
Time frame: 7/1/2011 - 6/30/2013
Grant Number: 69123