JFS Awarded Grants from the Grotta Fund for Senior Care and the Merck Corporation, Inc.

Jewish Family Service of Central NJ was recently awarded a coveted grant through the Care Transitions Collaboration of the Grotta Fund for Senior Care to help reduce hospital readmission rates for seniors with congestive heart failure and/or chronic obstructive pulmonary disease. The grant is shared among JFS, Holy Redeemer Home Care, and Trinitas Regional Medical Center, all in Elizabeth, NJ. In addition to the Grotta Fund for Senior Care, the Merck Corporation, Inc. has awarded JFS a grant to supplement the program with additional nursing hours.

The collaboration is based on the Mary Naylor Model of Care Transitions, an evidence based program from the University of Pennsylvania School of Nursing. Using this model as a framework, JFS and Holy Redeemer have hired two Health Coaches, who are experienced nurses, to assist patients navigate through care transitions from the hospital to Medicare certified Home Care, to Long Term Care. The Coaches meet the client while they are still in the hospital and make their follow up medical appointments within one week of hospital discharge. They keep a close watch on the client with home visits, telephone contact and accompanying the client to the physician to ensure that the client discusses all pertinent issues with the physician and follows the recommended course of care and medication. The goal is to avoid re-hospitalization during this four month period.

At this early stage of the program, there are currently thirty clients enrolled in the program. The Agency is grateful for these grants that will help the Older Adult Services Department expand and improve the quality of services to the Union County clients who have serious medical problems and who are over the age of sixty.