Robert Wood Johnson University Hospital in Hamilton, N.J., has partnered with Jewish Family and Children’s Services of Greater Mercer County to support care transitions for 350 chronically ill older patients. Patients will receive a transitions coach following hospital discharge for education, support, and encouragement to keep appointments with their physicians. This “coach” will develop a plan of care for the patient, making one hospital visit, one home visit, and three phone calls, says Joyce Schwarz, the hospital’s vice president of quality and the project’s director.
The hospital received a $300,000 grant under the New Jersey Health Initiative from the Robert Wood Johnson Foundation to use an evidence-based intervention to improve care transitions and reduce readmissions, acting as a bridge between hospital personnel and community physicians.
