Robert Wood Johnson University Hospital
New Brunswick • Somerset

Collaborative Approach Focuses on Chronic Health Conditions

August 15, 2011
Somerset Medical Center is collaborating with the Community Visiting Nurse Association (CVNA) of Somerville and six other area health providers to improve care for people with chronic health conditions, such as congestive heart failure.

CVNA has received a grant from the Robert Wood Johnson Foundation through its New Jersey Health Initiatives program to support the “CARE” program, designed to reduce the number of patients who return to the hospital as a result of difficulty managing chronic health conditions. 

The program termed “CARE,” A Collaborative Approach to Reach Patient Empowerment, will utilize an Advanced Practice Nurse to follow patients through “transitions of care” from the hospital to all other levels of care. It will use patient-centered initiatives including customized disease management workbooks, personal health diaries, individual scales, support groups and educational offerings to assist individuals to increase their knowledge and comfort with self management. Key monitoring processes will include transfer communications, medication reconciliation, and patient satisfaction. 

CARE is a collaborative effort among eight Somerset County providers seeking a joint approach to provide quality care, patient self management and empowerment to individuals with chronic diseases such as Congestive Heart Failure and Diabetes. In addition to Somerset Medical Center and CVNA, the program's collaborating providers are Arbor Glen at Bridgewater, Bridgeway Care Center, Somerset Valley Rehabilitation & Nursing Center, Green Knoll Care and Rehabilitation Center, Greenbrook Manor Nursing and Rehabilitation Center, and Raritan Health and Extended Care.

“Community VNA is proud to be on the forefront of new ideas and initiatives to promote the health care needs of our communities,” stated Alyce Brophy, President/CEO of Community VNA. “No single organization can navigate the issue of chronic illness alone. We knew we needed a shared vision and plan for managing chronic illness and improving our patient’s ability and desire to manage their diseases.” 

“We are proud to partner with the Community Visiting Nurse Association and our other local health care providers to take a broad approach to addressing the community issue of chronic disease,” said Alyssa Kizun, Director of Care Management at Somerset Medical Center. “By working together and consolidating our resources, we will make a difference in improving the health of our communities.”