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Grant eases transition from hospital to home
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Grant eases transition from hospital to home

For elderly patients, experts to monitor drugs and after-care

A symposium hosted by the Grotta Fund earlier this year led the way for the program Jewish Family Service of Central New Jersey will be working on to reduce rehospitalization of chronically ill seniors.
A symposium hosted by the Grotta Fund earlier this year led the way for the program Jewish Family Service of Central New Jersey will be working on to reduce rehospitalization of chronically ill seniors.

For a group of elderly patients discharged after treatment at Trinitas Regional Health Center in Elizabeth, life at home might get a whole lot safer.

Thanks to a new grant designed to improve the quality of life for seniors, when they leave the hospital they won’t have to figure out complicated drug and diet routines for themselves.

Instead, they and their caregivers will have professionals navigating the transition for them, coaching them on their daily regimen, and providing follow-up monitoring.

The grant, for around $100,000, comes from the Grotta Fund for Senior Care of the Jewish Community Foundation of MetroWest NJ. It is being divided on a 40/60 percent basis between Jewish Family Service of Central New Jersey and Holy Redeemer Home Care New Jersey North, both working in collaboration with Trinitas.

It is one of three grants totaling close to $300,000 awarded in July by the Grotta Fund to hospital and home-care partnerships in the region. The other two are for comparable transition-care programs in Essex and Morris counties.

The goal is both to improve quality of life by sparing seniors the trauma of repeated hospital stays and to dramatically cut medical costs. According to a press release issued by Grotta this week, such transition-care programs may be able to save Medicare $17 million annually.

“Each grantee is expected to achieve multiple impacts, including better care coordination, lower costs, improved communications, and higher quality person-centered care,” said Grotta Fund director Renie Carniol in the statement. “In addition, seniors will become better skilled at taking an active role in their care transitions.”

Carniol told NJJN that the three programs that received the grants — all based on models that have proved successful elsewhere — were chosen from 10 or 11 proposals. They emerged, she said, following a symposium hosted by Grotta this past winter that drew around 140 participants and a number of “the nationally recognized gurus in the field.”

‘Changing the system’

The 30-day rehospitalization rate for people over 65 is between 20 and 25 percent; for those with illnesses like chronic heart or lung congestion and diabetes, it can range from 30 to 90 percent, Carniol said.

Participants are obliged to track their results and report in detail on their findings, so that other organizations can learn from their experiences.

“These approaches are really changing the delivery system for health care. We all think this is the future,” said Carniol.

The transition-care model to be used in the Union County program was created by Dr. Mary Naylor of the University of Pennsylvania. Like their Holy Redeemer counterparts, JFS staff members, led by nursing services director Karen Winter, are receiving intensive training and guidance in the coaching, monitoring, and reporting techniques developed by Naylor.

Central JFS executive director Tom Beck said it would be ideal if all seniors emerging from hospital care could be given such care. “But we have to start somewhere,” he said.

Since becoming part of the Jewish Community Foundation in 2003, the Grotta Fund has awarded grants totaling $3 million to nonprofit organizations in Essex, Morris, and Union counties that provide critical health, social service, home safety, and socialization programs and services.

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