Improving transitions in care: Underwood-Memorial Hospital's Transition in Care program

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.Underwood-Memorial Hospital (UMH), is a community-based, 305 licensed-bed acute care hospital, with clinical affiliations with Thomas Jefferson University and Hospital. This project is unique in that UMH will be assembling and integrating several of the best practices in the country in the area of medication access, adherence to prescribed therapy and patient education, and is designed to improve patient outcomes by preventing avoidable hospital re-admissions and post-discharge adverse events, and reducing duplication of services and resources. The target population is 3,000 patients from Gloucester, Camden and Salem Counties age 65 and over with multiple chronic conditions who are re-admitted within 30 days and/or have been admitted to UMH six times or greater in the past 12 months. Lessons learned from a recent pilot Care Transitions Program developed by the UMH Family Medicine Residency Program will be incorporated in this project. The goal of the pilot is to improve access and quality of care for patients at risk of poor outcomes during the transition from the hospital into the community. Due to the early success and positive feedback of this program, similar discharge-prep and post-discharge follow up communication plan of care with patients and providers has been expanded to the hospital's five-star Transitional Care Unit as well as the Acute Care of Elders Unit. In preparation for this effort, project partners have started working together to design a care transition program that begins at time of entry in the UMH system and coordinates transition coaching and case management services assisted by high impact, low-cost, state-of-the-art technology and tested telemedicine interventions to facilitate an optimal patient outcome.

Grant Details

Amount Awarded $300,000.00

Awarded on: 6/29/2011

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

Grant Number: 69117


Inspira Medical Center Woodbury, Inc.

509 North Broad Street
Woodbury, 08096-1617


Denise Campo
Project Director


Peter A. Kaprielyan
Project Director