Perfect partnership

From left, Morristown Medical center nurse manager, Patricia Primmer; Trish O’Keefe, MMC director of nursing and acute care services; and Brandee Fetherman, MMC nurse manager.

Exceptional Parent magazine published an article in its March issue about Matheny’s transition nursing care program—the assignment of a full-time transition nurse who accompanies our patients to acute care hospitals and is available for consultation with the hospital’s staff. Our partner in this project is Morristown Medical Center, and the article focused on the spirit of cooperation that exists between the two institutions.

Pointing out that Matheny has “a very complex patient population,” Morristown nurse manager Patricia Primmer, RN, said having “someone who can educate the staff on what care is needed is very important.” Added MMC nurse manager Brandee Fetherman, RN: “Some of our staff have never seen people with these conditions before. The apparent behavior that is observed may be totally different from what the behavior truly is.” Morristown’s physicians and residents “have learned from this model,” said Trish O’Keefe, RN, MMC’s director of nursing and acute care services. The average length of stay for Matheny patients at Morristown, she added, used to be longer, but “because of the transition program, they’re now often able to return to Matheny sooner.”

Jeanne Lavelle, RN, Matheny’s transition care nurse for hospitals, said one reason the program is working so well is that “everything started at the top with Trish’s support and trickled down. Whenever we had our initial meetings, they were fully attended by the nurse managers. I see them all the time; they know who I am. I have my Morristown ID, and sometimes I have participated in rounds.”

Transition care nurse for medical trips Cathi Losavio, RN, left, and Jeanne Lavelle, RN, transition care nurse for hospitals.

In July 2011, Matheny received a $300,000 grant from the New Jersey Health Initiatives Program of the Robert Wood Johnson Foundation to develop a model to improve transitions to and from acute care hospitals for adults with chronic neurologic disabling conditions. The grant period ended June 30, 2013, but, based on the program’s success, Matheny will continue to fund and expand it by creating a division within our nursing department, integrating our specialized resources to improve transitions during all healthcare encounters. And the program will be broadened to include children.

Here’s how the existing program works:

• A full-time transitional nurse accompanies patients to acute care hospitals, encouraging full use of information in the patient’s “mini-record”.

• The nurse follows patients throughout their hospitalization to facilitate discharge planning plus inpatient care and post-hospital transition.

The program is being continued beyond the grant period because we have strong evidence that our primary end goal —the reduction of re-hospitalizations within 30 days of discharge—was achieved.  In the 10 months preceding the implementation of our transition program, six of the 24 patients who were hospitalized were re-hospitalized within 30 days (25%). During the project period—September 2011 thru June 2013—four of the 65 patients who were hospitalized were re-hospitalized within 30 days (6.25%).

In addition, satisfaction data were gathered from Matheny patients, staff and families showing positive results overall. And smoothness of discharge plans being implemented from the acute care locations back to Matheny was greatly improved, based on patient outcomes.

Our partners in this project are Atlantic Health System’s Morristown Medical Center and Newton Medical Center, Robert Wood Johnson University Hospital and Somerset Medical Center.

At the Matheny School’s recent Open House, Matheny student Natalie Tomastyk talked about her work experience at the Gurukul Yoga Holistic Center with Ryan MacNaughton, assistant principal, special services, and Kathleen Simpson, special education case manager, at the Kittatinny Regional High School in Newton, NJ.

The Matheny School’s Transition program is designed to increase the independence of its students both within the school and in the surrounding community. One way that is accomplished is through community-based experiences and structured learning environments that simulate real-life working situations. Matheny students are currently receiving an opportunity to learn on-the-job skills at both the Bridgewater, NJ, Township Library and the Gurukul Yoga Holistic Center in Bridgewater.

Students also encounter an authentic work environment in the Tea Time Café, Matheny’s in-house school refreshment stand, equipped with an adapted cash register, AbleNet and Point-of-Sale technology. And they are able to enhance functional and social skills during weekly trips to local stores to apply what is learned in the classroom to real-world experiences.