Transition program success

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.