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Transitional Care Program Participates in National Webinar
Release Date: February 28, 2013

Sussex County Transitional Care Program Participates in National Webinar "The Best of New Jersey - Care Transitions Communities"

(Newton, NJ) The Sussex County Transitional Care Program (TCP) was invited to participate in a national webinar entitled "The Best of New Jersey - Care Transitions Communities." The event was sponsored by Healthcare Quality Strategies, Inc. (HQSI). This group is the Medicare Quality Improvement Organization for New Jersey, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Registrants included individuals from throughout the United States. Sussex County was one of only five selected to present Care Transitions data at this national event.

Representatives from Greater Trenton, Atlantic-Cape, South Jersey and Central Jersey communities joined Sussex County on Wednesday, June 25, 2014, to participate in a webinar that focused on sharing best practices across New Jersey, patient stories and lessons learned related to improving the safety of care transitions and reducing avoidable hospital readmissions in the community. Staff from each community focused their presentation on a specific aspect of their Care Transitions program: Atlantic-Cape "Community-wide Education Programs," Sussex County "Public-Private Partnerships," Central Jersey "Area Agencies on Aging and Care Transitions," Greater Trenton "Changing Culture in Post-acute and Long-term Care" and South Jersey "Patient Success Stories."

Representing the Sussex County Transitional Care Program at this event was Sarah Balzano, RN, Transitional Care Coordinator. Sarah presented data and interpreted how the TCP team navigated theory to best practices through a successful public-private partnership with the County of Sussex and Premier Health Associates (PHA), the largest medical group in Sussex County. She talked about the need to incorporate human services in the healthcare model, and since the Care Transitions program is based out of the Sussex County Department of Human Services, they were able to provide these services utilizing existing staff from Senior Services, Social Services, Division of Community and Youth Services, as well as the County's transportation system. Sarah explained that meeting with key PHA physicians was essential to determine their needs and what they believed their patients needed to develop a successful Transitional Care Program. Once the specific details were in place, a pilot program was designed.

The presentation disclosed impressive statistics, for example, in New Jersey from 2011 through 2013, there were 6,900 fewer admissions, nearly 3,000 fewer readmissions and over $26,000,000 saved in Care Transitions. During this same period, the top achievers in "Reducing Admissions" were Sussex County - 12.46%, Central Jersey - 10.79%, and Greater Trenton - 9.63%. Top achievers in "Reducing Readmissions" was Sussex County - 23.24%, Greater Trenton - 18.26%, and Atlantic-Cape - 16.95%. The top achievers in "Readmissions from Home Health Agencies" were Sussex County - 26.25% to 18.86%, Atlantic Cape - 22.82% to 20.64%, and Greater Trenton - 23.69% to 22.29%. This data represents a sample of the information given in "The Best of New Jersey: Care Transitions Communities" webinar. To view the entire HQSI presentation, go to http://www.sussex.nj.us/documents/dhs/2014/bestofnewjersey.pdf.

Daina Bungs, MPH Project Coordinator for Healthcare Quality Strategies, Inc. congratulated the speakers participating in this webinar for a job well done and for the excellent work achieved in their communities. It is their belief that there is statewide momentum building in the field of Care Transitions through provider and community education. For additional information on the Transitional Care Program, please contact Sarah Balzano, R.N., Transitional Care Coordinator, for the Sussex County Department of Human Services, at 973-579-0559 ext. 1247.

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