Projects in Transitions in Care

CARE - Collaborative Approach to Reach Patient Empowerment
2011
Status: Active
Grant Recipient: Community VNA (Somerset, NJ)
Description:

Utilizing an Advanced Practice Nurse in a shared position among eight community providers, the collaborative strives to …

Camden Coalition of Healthcare Providers - Improving Care Transitions for High Needs, High Cost Patients in Camden
2011
Status: Active
Grant Recipient: Cooper Foundation (Camden, NJ)
Description:

To improve care transitions for complex, costly, and high utilizing patients, with a goal of reducing unnecessary hospit…

I-Care 4 Health Transitions: Improving Care for a Health Transition using a 4-Tiered Approach to Collaboration Across the Continuum
2011
Status: Active
Grant Recipient: Foundation of University of Medicine & Dentistry of New Jersey (Essex, NJ)
Description:

The I-Care 4 Health Transition project builds upon a successful Department of Medicine project that tested the effective…

Improving the Health Care Transition Process for Persons with Developmental Disabilities & Medically Complex Conditions
2011
Status: Active
Grant Recipient: Matheny Medical & Educational Center (Somerset, NJ)
Description:

Matheny Medical and Educational Center is developing, with the cooperation of its acute care partners, a model to improv…

Transitional Excellence through Coordinated Systems
2011
Status: Active
Grant Recipient: Our Lady of Lourdes Health Foundation Inc. (Camden, NJ)
Description:

Transitional Excellence through Coordinated Systems (TECS) is an evidence based project, modeled on Project RED (Re-Engi…

Partnership for PIECE (Pateint-Centered Integrated Elder Care and Empowerment)
2011
Status: Active
Grant Recipient: Princeton HealthCare System (Mercer, NJ)
Description:

This project will address the transitional care needs of 6,600 recently hospitalized frail elderly patients over 70 year…

The Mercer Care Transitions Program (MCT)
2011
Status: Active
Grant Recipient: Robert Wood Johnson University Hospital - Hamilton (Mercer, NJ)
Description:

In partnership with Jewish Family & Children's Service of Greater Mercer County, Robert Wood Johnson University Hosp…

SBHCS Transition Program for the Frail Elderly with Dementia
2011
Status: Active
Grant Recipient: Saint Barnabas Health Care System (Monmouth, NJ)
Description:

The Transition Program at Monmouth Medical Center will serve people age 65 and older with dementia and multiple other ch…

Community Hospital-Based Integrated Delivery System, Centered Around Patient Transition of Care
2011
Status: Active
Grant Recipient: Underwood-Memorial Hospital (Gloucester, NJ)
Description:

Underwood-Memorial Hospital will assemble and integrate several of the best practices in the country in the area of medi…