Improving transitions in care: Saint Barnabas Health Care Systems' program for the frail elderly with dementia

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.Under this grant, the Saint Barnabas Health Care System (SBHCS) Foundation will implement the SBHCS Transition Program for the Frail Elderly with Dementia. Monmouth Medical Center, the Visiting Nurse Association of Central New Jersey, CareOne at King James, HealthSouth Rehabilitation Hospital of Tinton Falls, and Aetna will implement the project at the onset of the project period in Monmouth County. The target population for the Transition Program at Monmouth Medical Center is people age 65 and older with dementia and multiple other chronic conditions a population at high risk for adverse health outcomes, hospital readmission, and mortality. The two-year project will serve a cohort of 1,160 patients. The Transition Program consists of eight core components: (1) patient-identified goals and activities; (2) barrier and support resources identification; (3) patient and caregiver education; (4) prescription reconciliation and education; (5) multidisciplinary case conferencing; (6) development of a detailed, patient-specific My Care Plan; (7) 'receiving provider' notification; and (8) follow-up care and home visits. The Saint Barnabas Health Care System and Saint Barnabas, Clara Maass, Community, Kimball, and Newark Beth Israel Medical Centers will replicate the program in Ocean and Essex Counties by the end of Year 2. The SBHCS Transition Program is expected to decrease 30-day readmission rates, decrease Emergency Department visits, and be cost-effective.

Grant Details

Amount Awarded $300,000.00

Awarded on: 7/1/2011

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

Grant Number: 69121


Saint Barnabas Health Care System Foundation

95 Old Short Hills Road
West Orange, 07052-1008


Jessica Israel
Project Director