The Visiting Nurse Association of Somerset Hills, Basking Ridge, N.J., has received a grant from the Grotta Fund for Senior Care of the Jewish Community Foundation of Greater MetroWest N.J.
The funding will support a partnership focused on improving the care transitions of older adults between healthcare settings including the hospital, nursing rehabilitation facilities and their home. Through improved discharge planning, telehealth in-home monitoring and patient self-care coaching, the Transition to Independence program aims to decrease rehospitalizations of older adults at high risk because of their chronic conditions. Since this population is the most costly user of Medicare benefits, the program will help medical systems realize significant cost savings.
In fact, 14% of patients with six or more chronic conditions accounted for 55% of all Medicare spending on rehospitalizations, according to the Centers for Medicare and Medicaid Services.
The VNA of Somerset Hills, according to a news release, will be working in collaboration with Somerset Medical Center in Somerville, N.J., sub-acute nursing rehabilitation facilities and Community VNA to improve care transition efforts.
Through shared resources, improved communication and well-coordinated care between our partner providers, patients will experience a smooth and safe transition home, said Diane Brienza-Arcilla, RN, BSN, MSA, director of quality care management, VNA of Somerset Hills, in the release.
The partnership allows for a care transition coach, who will be an RN, to begin working with patients before discharge and returning home. A unique component of the VNA program is the early introduction of telehealth monitoring.
By introducing telehealth remote vital sign monitoring and medication management education prior to discharge, patients return home already taking their first steps toward self-management of their conditions and an improved quality of life, Brienza-Arcilla said in the release.
Patients receive a structured program of coaching and telehealth support for 90 days, gradually increasing their ability and confidence to independently manage their chronic disease and reduce risk of avoidable rehospitalization. A dietician will accompany program participants while grocery shopping to ensure they have a good understanding of appropriate foods for their diet.
The Grotta Fund provides grant support to agencies that benefit older adults and their families and help them to age in place independently, safely and with dignity in their homes and communities.