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Lourdes to Improve Transitional Care for the Elderly with $300K Grant from Robert Wood Johnson Foundation

Grant to help fund transitional care project for elderly patients

Our Lady of Lourdes Health Foundation has been awarded a $300,000 grant from the Robert Wood Johnson Foundation through its New Jersey Health Initiatives (NJHI) program to help fund the foundation’s Transitional Excellence through Coordinated Systems (TECS) project, announced Alexander J. Hatala, President and CEO of Lourdes Health System.  

The TECS project, lead by co-directors Ann B. Townsend, RN, DrNP, APN and Maryann Classick-Wallace, RN, BSN, is set to launch in September of this year. The project aims to manage and promote the effective transition in care for elderly patients with chronic health conditions and complex social issues. The purpose of the project is to prevent avoidable readmissions through transitioning the individual from the care of the hospital team to self-care with community support.  

“Lourdes is honored to be one of the nine recipients chosen to receive NJHI project funding,” Hatala said. “With this grant, our foundation intends to bridge the gap that so often occurs between when an elderly patient is hospitalized and when they are discharged to outpatient care. In doing so, we aim to reduce unnecessary readmissions and associated costs while improving the quality, care and overall transition process for our elderly patients.”  

The grant will be used to address an important health issue that impacts seniors. Currently, one in three elderly patients is re-hospitalized within 90 days due to potentially avoidable complications. This not only has negative health consequences for the patient but also impacts family and caregivers. Financially, the impact of avertable readmissions results in an estimated $17 billion spent each year. The TECS project strives to reduce its footprint by cutting readmission rates to 20 percent or less by 2012.

Common factors that contribute to the problem of high re-admission rates include: medication discrepancies (66 percent), lack of caregiver communication that affects quality of patient care (25 percent), diagnostic test results that are unknown at discharge to patient and/or next care provider (40 percent) and a delay in post-hospitalization visits during the transition period.  

“Conventional discharge practices are often fragmented due to a lack of cohesiveness in the transition process from hospital to home. Lourdes’ goal is to change this process by redefining the way we transition our patients through enhanced education, communication and support,” said Dr. Townsend.

Patients enrolled in the Lourdes project will work closely with a designated Discharge Advocate (DA), who will serve as the main point of contact and provide health education, care coordination and patient/care-giver coaching to the patient. The DA will also provide the patient with an After Hospital Care Plan which will act as a blueprint for post-hospital care. Additionally, telephone-based medication support will be provided within 48 hours of hospital discharge by a staff pharmacist.  

Community alliances for the TECS project will provide health support, chronic illness management and end-of-life care. Alliance partners include: The Lourdes Wellness Center, LIFE at Lourdes also known as PACE (Program for All-Inclusive Care for the Elderly) and Lourdes Medical Associates (LMA). Additionally, Bayada Nurses Home Care and Compassionate Care Hospice will support chronic illness home care and palliative and hospice care services.

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