Improving Transitions in Care

Dates of Project: July 2011 through September 2013

Description: Monmouth Medical Center, one of six hospitals within Barnabas Health in northern New Jersey, was the initial site for the Transitions in Care Program.  It partnered with other  organizations—the Visiting Nurse Association of Central Jersey, CareOne at Kings James, HealthSouth Rehabilitation Hospital of Tinton Falls, and Aetna.

The Transitions in Care program developed personalized care plans based on input from the patient and the caregiver, and taught them about the patient’s diagnoses, treatment, medicines, and upcoming care transitions.

Team members met weekly to review the care of each patient. After hospital discharge, case managers called patients and caregivers with a reminder to see the referring physician and to follow up on the care plan. They sent the care plan to the referring physician or long-term care facility. The Visiting Nurse Association of Central Jersey made home visits if appropriate.  CareOne at King James and HealthSouth Rehabilitation Hospital of Tinton Falls provided rehabilitation and therapy services.

Key Results

  • Project staff enrolled 640 frail older adults with dementia and at least one other chronic condition in the Transitions in Care program.

  • Project staff developed a multidisciplinary team to manage transitions in care and trained 272 health care professionals, social services staff, and others at Monmouth Medical Center and partnering organizations.

  • The readmission rate at Monmouth Medical Center decreased by more than 39 percent (from 14.8% to 9%) among Transitions in Care program patients.

Two sidebars in the report tell stories of patients and their caregivers.