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Sussex County Leads Transitional Care
Release Date: January 25, 2012

Sussex County Leads Transitional Care

The Sussex County Department of Human Services along with its partners, Newton Medical Center, Saint Clare's Hospital System and Bridgeway are leading the way to bring Transitional Care services to Sussex County.

In an effort to inform and engage community health care and human services providers, the Department of Human Services, Division of Senior Services is pleased to announce that Dr. Mary Naylor has been invited to discuss the innovative Transitional Care Model. Mary D. Naylor, PhD, RN, FAAN, chief architect of the nationally acclaimed Transitional Care Model (TCM), will be leading a conversation on transitional care for health care and human services providers on February 8, 2012, at the Sussex County Community College Performing Arts Center.

The Transitional Care Model is an evidence-based innovation bridging in-hospital, post-acute and home follow-up care for at-risk chronically ill older adults. TCM emphasizes patient-centered coordination and continuity of care, prevention and avoidance of complications and subsequent hospitalizations, all accomplished through the active interdisciplinary collaboration of physicians, nurses, social workers, family care-givers and the network of community human service agencies.

The Transitional Care Model (TCM) provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions. The heart of the model is the Transitional Care Nurse (TCN), who follows patients from the hospital into their homes and provides services designed to streamline plans of care, interrupt patterns of frequent acute hospital and emergency department use and prevent health status decline. While TCM is nurse-led, it is a multidisciplinary model that includes physicians, nurses, social workers, discharge planners, pharmacists and other members of the health care team in the implementation of tested protocols with a unique focus on increasing the ability of patients and caregivers to manage their care.

The Sussex County Department of Human Services is proud to announce the successful completion of the nationally recognized Transitional Care Model, Transitional Care Nurse course through the University of Pennsylvania by Sarah Balzano, RN. Nurses who successfully complete this course will be eligible to assume a position as a TCN and implement the findings from the TCM program of research into real world clinical applications. "Transitional care provides critically needed service continuity to at-risk populations at a most vulnerable point in their health care. Along with the Department of Human Services, we hope to actively engage each participant involved in the care of a transitioning patient. Facilitating communication and continuity across the multiple healthcare and human service providers is essential," said Sarah Balzano, RN.

"The fact that we have someone skilled in this approach, through a nationally recognized program, will enable us to provide enhanced services to the citizens of Sussex County. Transitional Care is an innovative approach to providing comprehensive services to citizens in order to improve care and reduce cost," said Stephen Gruchacz, Administrator for the Department of Human Services. "The Department encourages human service providers, physicians, nurses, rehabilitation professionals, students interested in nursing and human services, and caregivers to attend this educational program. We now understand that it is necessary to utilize a broader set of services and resources to provide physicians, patients and family caregivers with the tools they need to coordinate care and effectively manage health."

For more information on "Understanding Transitional Care: A Conversation with Mary Naylor, PhD, RN, FAAN," please call Sussex County Division of Senior Services at 973-579-0555 or email: seniorservices@sussex.nj.us.

*** Program Flyer and Registration Form ***


A program of the Department of Human Services, Stephen R. Gruchacz, Administrator, Division of Senior Services, Lorraine Hentz, Division Director, One Spring Street, Newton, N.J. 07860 Office Hours: 8:30 AM to 4:30 PM Phone 973-579-0555 Fax 973-579-0550 seniorservices@sussex.nj.us





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