Improving transitions in care: Princeton HealthCare System's Partnerships for Patient-Centered Integrated Elder Care and 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.Over the two-year grant period, Partnerships for PIECE will create an innovative initiative designed to address the transitional care needs of 6,600 recently hospitalized frail elderly patients over 70 years old coping with multiple chronic and acute morbidities during 60 day episodes of care in Central New Jersey. This initiative represents a collaboration among Princeton HealthCare System, a private non-profit organization; New Jersey Goals of Care, a private nonprofit organization; and nine long-term care/skilled nursing facilities. The project's three-tiered approach is designed to improve integration and information exchange during care transitions as follows: (1) Consulting with and training partners will strengthen transitional communications; (2) The Navigation Program will support patient transitions to the home, and (3) A comprehensive patient registry will improve and streamline electronic communications among partners. Notably, innovations such as the revised POLST form will empower patients as well as reorganize and better focus care providers on primary dialogues concerning patient goals, thereby enhancing care transitions. The project expects to improve patient care, communication and readmission rates, as well as to establish project sustainability after 2013.

Grant Details

Amount Awarded $300,000.00

Awarded on: 6/27/2011

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

Grant Number: 69119


Princeton HealthCare System

253 Witherspoon Street
Princeton, 08540-3211


Susan G. Lorenz
Project Director


Kathleen Seneca
Project Director