Three grants were awarded in Spring 2011 totaling almost $300,000. These grants supported Grotta’s Initiative to improve care transitions and reduce rehospitalizations.

• Agency: Holy Redeemer Home Care, NJ North “DBA” Visiting Nurse and Health Services, Inc.
  Project: Collaboration of Acute and Long-Term Home Care Agencies to Prevent Re-Hospitalizations
  Grant Period: September 1, 2011- August 31, 2012
  Goal: To hire health coaches and coordinate efforts to ensure continuity of care, educate clients and caregivers and reduce re-hospitalizations of patients diagnosed with Heart Failure and/or Chronic Obstructive Pulmonary Disease. Holy Redeemer will employ an evidence-based model of care, the Transitional Care Model, developed by Mary Naylor.
  Partnership: JFS of Central NJ and Trinitas Regional Medical Center
• Agency: Newark Beth Israel Medical Center Foundation
  Project: Newark Beth Israel Medical Center CHF Transitions Project
  Grant Period: September 1, 2011- August 31, 2012
  Goal: To improve transitional care, increase coordination and timeliness of care and reduce the hospital’s readmissions rate, the collaborators will work with a new Transitional Care Nurse and members of the Congestive Heart Failure Task Force and implement Project RED (Reengineering Discharges)
  Partnership: NBIMC, Home Care Services, Saint Barnabas Health Care LINK, Patient Concierge, Saint Barnabas Health Care System, Chancellor Specialty Care Center
• Agency: Saint Clare’s Foundation
  Project: Saint Clare’s Cares: Caring Transitions for Elderly Heart Failure and Diabetes Patients
  Grant Period: September 1, 2011- August 31, 2012
  Goal: To improve health outcomes, reduce preventable readmissions and emergency room visits, improve the transition of patients for patients with heart failure and diabetes, the hospital has created a new Caring Transitions Program. Following the Transitions Care Intervention model, developed by Dr. Eric Coleman, the partnership organizations and new care transitions nurses, coach/navigators, are committed to reciprocal orientation and training programs and use of the nurse navigators to improve transitional care. Three grants were awarded in Spring 2011 totaling almost $300,000. These grants supported Grotta’s Initiative to improve care transitions and reduce rehospitalizations. Saint Clare’s Medical Center, Visiting Nurses Association of Saint Clare’s, Visiting Nurses Association of Northern NJ, Care One at Morris County.