WEST ORANGE — Barnabas Health Foundation is the recipient of a two-year, $300,000 grant from the Robert Wood Johnson Foundation (RWJF) through its New Jersey Health Initiatives program. The money will be used to fund the Barnabas Health Transition Program for the Frail Elderly with Dementia, a program designed to improve patients’ self-management of their care and decrease hospital re-admissions among this vulnerable population afflicted with multiple chronic health conditions. The program will be developed at Monmouth Medical Center, an affiliate of Barnabas Health serving Monmouth, Essex and Ocean counties, and then expand to other Barnabas Health affiliates throughout New Jersey.
“The population of individuals 65 and older with dementia and other chronic conditions is at high risk for adverse health outcomes, hospital readmission and mortality,” says Allan R. Tunkel, MD, PHd, Chairman of the Department of Medicine at Monmouth Medical Center and the Project Director. Dr. Tunkel explains that the Transition Program consists of eight core components to enhance care for this target population. Among them are identifying achievable patient goals, helping to remove barriers to care, improving patient and caregiver education, creating safe pharmaceutical regimens, and developing a patient-specific plan of care.
Among the key objectives of the program are to screen 900 patients for frailty, dementia, and co-morbidities annually, to record patient-identified goals and objectives, identify barrier and support resources, conduct patient and caregiver education, conduct multidisciplinary case conferencing and develop a detailed, patient-specific My Care Plan for each patient. We will conduct follow-up calls and home visits through collaborating home health agencies.
The Wallerstein Foundation for Geriatric Life Improvement made a $25,000 grant to the Barnabas Health Foundation as a matching grant to the $300,000 awarded by Robert Wood Johnson Foundation through its New Jersey Health Initiatives program.
Partnering with Barnabas Health will be the Visiting Nurse Association of Central NJ, Care One at King James, HealthSouth Rehabilitation Hospital of Tinton Falls, and Aetna. Partners will participate in multi-disciplinary conferences and serve as liaisons to facilitate the implementation of the Transition Program as well as receive training and create protocols to implement and utilize the program’s core components to improve care.
RWJF’s New Jersey Health Initiatives program seeks to identify projects that present innovative strategies and collaborations to resolve health care needs in New Jersey communities. The grant awarded to Barnabas Health for the Transitions Program was among only nine projects out of 27 that were approved for funding in 2011.
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