Making successful transitions

Morristown Medical Center is one of Matheny's partner hospitals in its transitional nursing program.

Matheny has completed the first year of its program, designed to improve the quality of transition care for patients who are admitted to acute care hospitals, and the initial results have been very favorable. A grant from the Robert Wood Johnson New Jersey Health Initiatives program enabled us to provide transitional nursing care to inpatients, residents of our group homes and outpatients from the Matheny Center of Medicine Dentistry.

In the first year of this program’s operation, from July 1, 2011, to June 30, 2012, twenty-eight patients were followed into and from our partner hospitals Morristown Medical Center, Robert Wood Johnson University Hospital in New Brunswick and Somerset Medical Center in Somerville. The program ensured a smooth transition among care settings and the transmittal of vitally important patient information, such as a patient’s medical history and suggested strategies for communicating with non-verbal patients. In addition, information about individual orthopedic and positioning needs and other specific medical needs were readily available.

The project’s goal was to reduce the number of hospital readmissions of patients with developmental disabilities. The readmission rate of Matheny patients since the project’s beginning has been 7.1%. In the 10-month period immediately preceding the start of the program, the readmission rate was 25%.

Judy Hahn, RN, with adult medical day patient John Edwards.

In June 2005, Judy Hahn, RN, began work as a per diem nurse at Matheny after a hiatus of 12 years from nursing. At first, the Long Valley, NJ, resident admits that, “I didn’t know if I could do it.” Her previous nursing experience had been as a pediatric nurse in a Bridgewater, NJ, doctor’s office before she pursued careers as a personal trainer and partner in a New York City-based multimedia company.

But, about three weeks into the new job, she realized “how much this population has to offer. I came to feel a certain responsibility toward the students and patients.” As she became more comfortable at Matheny, “it ‘made my day’ to know that I could get through to them.”

Then, in April 2011, Matheny’s adult medical day nurse retired, and Hahn moved into that role. Plus, she recently agreed to be the alternate for Matheny’s transitional nurse, Jeanne Lavelle, RN, who accompanies Matheny patients when it is necessary to transport them to an acute care hospital.

The transitional nurse position, made possible by a $300,000 grant from the Robert Wood Johnson Foundation through its New Jersey Health Initiatives program, involves following patients throughout their hospitalization at acute care facilities to make discharge planning easier and to foster development of resources needed for appropriate inpatient care and effective post-hospital transition. Matheny’s partners in this project are Morristown Medical Center in Morristown and Robert Wood Johnson University Hospital in New Brunswick.

“While it’s always hard to get your points across in an emergency room setting,” Hahn says, “once a patient is admitted, the hospital staffs are very appreciative of our presence. They thank us over and over because they don’t know our population. We’re seeing more continuity of care.  It’s not just a current situation; it’s the patient’s whole history that has to be dealt with.”

Since joining the nursing staff at Matheny, Hahn has never looked back. “I’m constantly amazed at what we are able to do as a team here,” she says, “and all the love that is given to our patients. All the employees here pull together for each other.”