Improving transitions in care: Robert Wood Johnson Hospital, Hamilton, and Jewish Family and Children's Services of Mercer County's joint 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.Robert Wood Johnson University Hospital Hamilton (RWJH) and Jewish Family and Children's Services of Greater Mercer County (JFCS) will work together to create the Mercer Care Transitions Program (MCT). A partnership between a hospital and a community agency, MCT will use the evidence-based Care Transitions InterventionSM (CTI) model to improve care transitions for at least 350 Mercer County residents hospitalized with congestive heart failure and/or diabetes, at least one other chronic condition, and one or more social vulnerabilities (primarily advanced age, low income, and/or disability). Service areas will include Hightstown, Trenton, Hamilton, Mercerville, Yardville, Ewing, Lawrenceville and Washington Township. As lead organization, RWJH will manage and help govern the project, distribute grant funds, and submit required reports. It will contract with JFCS to act as expert consultant in the CTI model, train and provide field oversight to the Transitions Coach, access community services, prepare program materials, and manage program communications. Expected outcomes include reduced re-hospitalization rates, resulting in lowered costs to patient, hospital, and insurance companies, and improved quality of care.

Grant Details

Amount Awarded $300,000.00

Awarded on: 6/22/2011

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

Grant Number: 69118


Robert Wood Johnson University Hospital Hamilton

One Hamilton Health Place
Hamilton, 08690-3599


Judith Ann Millner
Project Director


Joyce Schwarz
Project Director