Improving transitions in care: New Jersey Medical School's I-Care 4 Health Transition project

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.Disease management programs that assist patients in chronic illness self management have been shown to reduce medical costs and reduce the burden of inpatient hospitalization. Funds under this grant to the New Jersey Medical School will be used for the I-Care 4 Health Transition project to follow up on a successful pilot completed in the area of diabetes self management which involved utilization of a transitional care coordinator (APN with case management skills), patient navigators, and health educators. The current two-year project will extend this model to target a cohort of 500 adults, recently discharged from hospital, with co-morbidities, especially diabetes, hypertension, neuropathy, and vision loss. The target group will be principally individuals of African and Caribbean descent and low health literacy. The project will involve four levels of providers and will utilize electronic medical records to document intervention during the inpatient stay to six months post-hospitalization, with services following patients back into the community and to multiple providers. The project is a collaboration involving two health universities (UMDNJ and Rutgers) as well as community providers (Essex County Visiting Nurse and Newark Community Health Center, an FQHC.

Grant Details

Amount Awarded $300,000.00

Awarded on: 6/24/2011

Time frame: 7/1/2011 - 9/30/2013

Grant Number: 69116


Foundation of the University of Medicine and Dentistry of New Jersey

Tower II, Suite 850
120 Albany Street
New Brunswick, 08901-2126


Melissa Scollan-Koliopoulos
Project Director