UMDNJ Program Helps Patients Avoid Return Visits

The University of Medicine and Dentistry-University Hospital has received a $300,000 grant from the Robert Wood Johnson Foundation for a program to help patients avoid re-hospitalization, the Newark-based facility announced in a statement.

The “I CARE-4 Healthcare Transition Project,” which is also being funded by the Healthcare Foundation of New Jersey and implemented by the Visiting Nurse Association Health Group, addresses recently released patients who find themselves quickly returning to the emergency room.  

“We hope to prevent discharged patients from unnecessarily returning to the hospital within the first 30 days of their discharge, and as a result, improve their health-related quality of life,” said Melissa Scollan-Koliopoulos, EdD, APRN-BC, CDE, BC-ADM, assistant professor of medicine, Division of Endocrinology, Diabetes and Metabolism, UMDNJ-New Jersey Medical School.
Dr. Scollan-Koliopoulos and David Bleich, MD, associate professor and chief, Division of Endocrinology, Diabetes and Metabolism, are serving as co-project directors for the grant.  The overall goal, they said, is “improving care for a healthy transition using a four-tiered approach.” 

 The four tiers of care include a certified home health aide/patient navigator, registered nurse, advanced practice nurse (APN) and physician team.

According to Dr. Scollan-Koliopoulos, discharged patients often return to the hospital and go to the emergency room when they should not.  Other patients, she said, fail to go to the emergency room when they should. Such patterns contribute to excessive health care costs and disparities in health outcomes. A significant aspect of the project, Dr. Scollan-Koliopoulos said, is that it helps patients distinguish between needing to visit the emergency room and knowing their needs will be met by seeing a primary care physician.

The I CARE-4-Healthcare Transition Project targets patients who do not have a regular primary care physician and have one or more of the following diseases:  diabetes, cardiovascular disease (such as heart failure, uncontrolled hypertension and atrial fibrillation); respiratory disease (such as asthma, chronic obstructive pulmonary disease and pneumonia); HIV; and sickle cell disease.

“We selected diabetes, heart failure and pneumonia, because based on national Medicare statistics, patients with these conditions frequently return to the hospital within 30 days of being discharged,” Dr. Scollan-Koliopoulos said. The other conditions, sickle cell disease and HIV, were selected based on their prevalence in Newark.

 “Our goal is to extend the attention and care that patients receive from us beyond the four walls of UMDNJ-The University Hospital, thereby improving patient outcomes,” added Dr. Bleich.
Other program goals include educating patients about medications and overall health and wellness.  Participants also are linked to resources such as health insurance.