CARE TRANSITION PROGRAM TAKES AIM AT NJ HOSPITAL READMISSIONS
Grant Funds Home Care Partnership Benefiting Chronically Ill Older Adults
BASKING RIDGE, NJ (February 6, 2014) – The Visiting Nurse Association of Somerset Hills (VNA) has received a grant from the Grotta Fund for Senior Care of the Jewish Community Foundation of Greater MetroWest NJ to support a partnership focused on improving the care transitions of older adults between health care settings including the hospital, nursing rehabilitation facilities and their home. Through improved discharge planning, telehealth in-home monitoring and patient self-care coaching, the Transition to Independence program aims to decrease rehospitalizations of older adults at high risk due to their chronic conditions. Since this population is the most costly user of Medicare benefits, the program will help medical systems to realize significant cost savings. In fact, 14% of patients with six or more chronic conditions accounted for 55% of all Medicare spending on rehospitalizations, according to the Centers for Medicare and Medicaid Services (CMS).
The VNA of Somerset Hills will be working in collaboration with Somerset Medical Center, sub-acute nursing rehabilitation facilities and Community Visiting Nurse Association to improve care transition efforts. This includes using standardized educational and evaluation materials, bedside medication management, care plan review, coaching on lifestyle choices, and nutrition counseling. “Through shared resources, improved communication and well-coordinated care between our partner providers, patients will experience a smooth and safe transition home,” said Diane Brienza-Arcilla, RN, BSN, MSA, Director of Quality Care Management at the VNA of Somerset Hills.
The partnership allows for a Care Transition Coach (Registered Nurse) to begin working with patients prior to discharge and returning home. A unique component of the VNA of Somerset Hills program is the early introduction of telehealth monitoring. “By introducing telehealth remote vital sign monitoring and medication management education prior to discharge, patients return home already taking their first steps toward self-management of their conditions and an improved quality of life,” added Brienza-Arcilla. Patients receive a structured program of coaching and telehealth support for 90 days, gradually increasing their ability and confidence to independently manage their chronic disease and reduce risk of avoidable rehospitalization. A dietician will also be accompanying program participants while grocery shopping to ensure that they have a good understanding of appropriate foods for their diet.
The Grotta Fund for Senior Care provides grant support to agencies which benefit older adults and their families and help them to age in place independently, safely and with dignity in their homes and communities. “We are happy to support the VNA of Somerset Hills Transition to Independence project as the Grotta Fund is keenly aware of the importance of reducing re-hospitalizations of Medicare beneficiaries and the need to improve quality of care from one setting to another,” said Renie Carniol, Director, Grotta Fund for Senior Care. Since 2003, Grotta has awarded more than $3.9 million dollars in grants to 49 agencies benefiting seniors.