Transition Patient Services to Support Underwood-Memorial Hospital Implementation of Care Transition Services

TREVOSE, PA – Transition Patient Services (TPS) has been selected by Underwood-Memorial Hospital, Woodbury, NJ, to help support the design and implementation of the hospital’s transition of care system. Underwood Memorial Hospital has been awarded a two-year, $300,000 grant from the Robert Wood Johnson Foundation (RWJF) through its New Jersey Health Initiatives (NJHI).

The grant supports the establishment of a Community Hospital Based Integrated Delivery System, Centered around Patient Transition of Care. The hospital projects that 1,500 patients annually, aged 65 years and over, will receive services supported by the grant.

“We are excited to be a part of the transition of care process at Underwood,” says Christopher Di Lascia, president & CEO of TPS. “Underwood’s was one of nine projects to receive this funding through NJHI, reassuring us that we are launching an innovative strategy to bring improved health care to the residents of communities served by this award winning hospital.”

“This project is unique and exciting,” notes Barbara Roehl, MD, MBA, geriatrician and the chief clinical integration officer for Underwood who will direct the grant. “The intention of this is to ensure that our patients receive, and then take their prescribed medicines properly, and receive the appropriate care services once they are discharged from Underwood to the next level of care. Also important to a successful transition is the patient’s involvement in disease and medication self management, recognition of health issues or “red flags” that need attention, and timely outpatient follow-up. We believe TPS will play a critical role in our achieving these goals.

“The experts have told hospitals that we have to remove the word ‘discharge’ from our vocabulary. In the future, Underwood, as a health care provider, will never lose responsibility for that patient’s well-being once they are no longer in a hospital bed—under the hospital roof. The patient transitions to home, or skilled nursing facility, or a long-term care nursing facility—levels of care that Underwood is now partnering with in this effort.”

Underwood’s partners in this Transitions of Care start first, and foremost, with the patient and the patient’s caregivers.

Then, depending on the patient’s needs, TPS will help connect the patient with an expanded network to include a local pharmacy, coverage for prescription and co-pay assistance for the uninsured, rehabilitation and nursing homes, home care, and the Gloucester County Division of Senior Services.

The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful, and timely change. For more than 35 years, the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need—the Foundation expects to make a difference in your lifetime. For more information, visit www.rwif.org.

Underwood is a 305-licensed bed, acute care, non-profit hospital with a medical staff of over 400 physicians, and is Gloucester County’s largest employer.