VOLUME 14 NUMBER 1 SPRING 2012 www.saintclaresfoundation ...

12 SPRING 2012 VISIONS
Grotta Fund for Senior Care Helps Launch
Transitions in Care Program
Keeping recently discharged patients from winding up back in the hospital is smart medicine. To
help patients with heart failure and diabetes avoid readmission to the hospital, Saint Clare’s recently
launched a new program called Transitions in Care.
Pictured (l-r): Regina Hanna, APN, Deborah Kline, APN, and Mary Beth
Wetzelberger, APN, from the Transitions in Care program.
The goal of the Transitions in Care
program is to reduce preventable hospital
admissions in these patients by 20 percent.
Responding to the need for improved
transitions in care, Eric Coleman, MD,
from the University of Colorado, created
the Care Transitions Intervention (CTI).
Since then, there have been successful CTI
implementations throughout the country
of the Coleman coaching model. Saint
Clare’s has implemented the CTI model.
Carol Diveny, Foundation Corporate
Relations Manager, coordinated the grant
effort that resulted in funding of $100,000
from the Grotta Fund for Senior Care
of the Jewish Community Foundation of
MetroWestNJ.
Dedicated to improving the lives of seniors primarily living in Essex, Morris and Union counties, the
Grotta Fund for Senior Care provides grant support to local agencies that benefit older adults and their
families, helping them to live independently and safely in their homes and communities. Grotta has
awarded more than $3 million dollars in grants to 45 agencies since 2003. These grants serve seniors
living in the MetroWest New Jersey area with innovative health and social service programs. Many
of Grotta’s grant-funded programs have become national models of care, addressed emergency or
emerging situations and replicated evidence-based programs. The program focuses on empowering
the patient to ensure the safe transition between healthcare providers and healthcare settings as the
patient’s condition or need for care changes.
Each patient enrolled in Transitions in Care is guided through the program by an advanced practice
nurse navigator, who helps patients clarify their goals for care, medication reconciliation, red flags, and
what questions to ask their physician. Patients are visited by their nurse navigator prior to discharge and
are also seen shortly after leaving the hospital. A key component of the Transitions in Care program is
follow-up after a patient is discharged. After the home visit, a series of three follow-up phone calls are
conducted to empower patients to work more effectively with their doctors.
The Transitions in Care team includes a skilled and dedicated group of cardiologists, registered
nurses, dieticians, pastoral care, nurse practitioners, social workers, case managers, pharmacists,
VNA of Sussex, VNA of Northern New Jersey, and Care One of Morris. Saint Clare’s will continue its
partnerships in caring. “This program is aimed at patients who return to the hospital with the same
diagnosis,” said Saint Clare’s cardiologist Dr. Michael Blick. “Empowering the patient and involved
caregiver to be more proactive in their healthcare is at the core of the program.”
For more information about the Transitions in Care program, please contact Mary Beth Wetzelberger,
APN, Deborah Kline, APN, or Regina Hanna, APN, at 973-983-5270.