The Grotta Fund for Senior Care is hailing the success of a grant program that has allowed hundreds of local elderly people to remain at home rather than unnecessarily return to hospitals.
Launched in 2011, the “Care Transitions” grant program has focused on discharge and post-hospital care for seniors. Grantees have used the money variously to assign a pharmacist to monitor medications in the home, provide a registered nurse to act as a “health coach,” and arrange for agencies to deliver provisions and healthy meals to needy seniors.
Various collaborations help agencies make house calls to newly released patients to ensure they are taking their medications properly, following prescribed diets, and showing up for doctors’ visits.
“Each of the grantees has helped people transition from hospital to home successfully,” said Grotta Fund director Renie Carniol following a Feb. 23 meeting at the Aidekman Family Jewish Community Campus in Whippany.
Grotta is an advisory council of the Jewish Community Foundation of Greater MetroWest NJ.
At the meeting, Grotta Fund board members heard reports from institutions that have received funds for the past four years. The grantees come from Essex, Morris, Union, Somerset, and Sussex counties.
Several grantees reported that readmission rates dropped from 20 to 12 percent or lower, after the grants enabled them to hire nurses, social workers, and pharmacists and expand collaborative partners in care.
All too often, said Carniol, “when people are discharged they may not know how to take care of themselves after they have been diagnosed with very severe diseases. Their quality of life tends to decline.”
Saint Barnabas Medical Center in Livingston, which received one half of its $84,000 grant beginning in July 2015 and will receive the second half this July, focused on post-hospital care for people with Chronic Obstructive Pulmonary Disease, because their readmission rates were higher than for people with other conditions.
The grant money has enabled Saint Barnabas to add a three-day-a-week pharmacist to join a nurse practitioner on its care transitions team, according to Jennifer Costello, the residency program director at Saint Barnabas.
“Pharmacists are so necessary because medication management is a huge component of COPD,” said nurse practitioner Dawn Howard. “Patients need to learn how to use their inhalers correctly. Sometimes patients space out their meds by taking them every other day because they can’t afford them, so the pharmacists can help them find equivalent drugs at cheaper prices. Having a pharmacist navigate the health-care system is huge.”
Pharmacist Jessica Bente found errors in prescriptions or a patient’s misuse of medication in 117 cases, out of a total caseload of nearly 300.
“It has been hugely effective,” said Howard. “Our readmission rate has gone down by 12 percent. That is a lot. We save millions in Medicare billings by decreasing the revolving door at our hospital.”
The pharmacist will become full-time when the second half of the grant is received in July. “A social worker would absolutely be a welcome addition to our team,” added Costello.
Maria Mullen, director of nursing services at Jewish Family Service of Central NJ, oversees a Care Transitions program in a three-way relationship with Trinitas Hospital and Holy Redeemer Home Care in Elizabeth.
“We provide ‘health coaching’ with a registered nurse,” she said, using a term that she said is intended to be more patient-friendly than “visiting nurse.”
Their program began in 2011 with a nurse practitioner and added a pharmacist in 2014. “The pharmacist made connections with community pharmacies, which were really good at suggesting discounts. That made a big difference,” said Mullen.
The program has served 177 clients in eastern Union County during the past year.
“We pay one or sometimes two visits plus make several phone calls to make sure the clients are on their way and their medicines are straight,” Mullen said.
“I think it is an amazing success because we serve a much-needed clientele who are uninsured or under-insured with very low health literacy.”
Language barriers complicate treatment for 66 percent of the clientele served by Trinitas who are Spanish-speaking.
“We were able to help people who fall between the cracks,” Mullen added.
There were some unexpected results. “One grantee was making progress in reducing unnecessary readmissions with patients with congestive heart failure disease, but did not reapply to Grotta for their third year of funding,” Carniol said. “Instead they leveraged their experience to apply and receive $13,000,000 in Delivery System Reform Incentive Payment program, a federal demonstration funding program.”
“Grotta was a catalyst in our achieving this funding,” said Phyllis Buttrick, the transitional care leader/DSRIP manager at Newark Beth Israel Medical Center.
Carniol also pointed to some challenges. “Some of the seniors involved in the care transition program are reluctant to have strangers coming into their homes, which reduces the acceptance rate of the program. We are pleased that the grantee teams have created ‘warm methods’ and information cards to overcome these fears.”
The programs also created large partnerships with other hospitals and community organizations, resulting in receipt of a four-year state demonstration grant and national recognition by Mary Naylor, the developer of the Transitional Care Model at the University of Pennsylvania, said Carniol.
Such partnerships have led, in Elizabeth, to Groundwork Elizabeth now providing needy seniors with fresh vegetables, and JFS of Central NJ and the Community Food Bank of NJ working together to deliver milk and frozen healthy meals to needy seniors.
“We awarded a total of $998,000,” said Carniol. “It shows how successful we can be with a little less than $1 million dollars.”