New Re-Hospitalization Prevention Project to Employ Home Health Aides

Certified home health aides will play an integral role in efforts to prevent re-hospitalizations when a new project at the University of Medicine & Dentistry of New Jersey (UMDNJ) is launched.

The “I CARE-4-Healthcare Transition Project,” designed to prevent discharged patients from returning to the hospital within the first 30 days after they leave, will utilize a four-tiered approach to care that includes a:

• certified home health aide/patient navigator
• registered nurse
• advanced practice nurse (APN), and
• physician team.

The certified home health aide/patient navigator will be responsible for visiting patients who are in the hospital and following up after they are discharged to the community, a hospital press release explains. The APN will provide care with “physician collaboration until a patient can see a primary care physician regularly.” [Scroll down for a further explanation of home health aides’ role in the program from co-director Melissa Scollan-Koliopoulos, Ed.D.]

Reduce Costs, Improve Health Outcomes

A key aspect of the project will be to help patients determine when they need to go to a hospital emergency room or when they should see a primary care physician instead, in order to reduce costs and improve health outcomes.

Educating patients about medications and overall health and wellness, as well as connecting them to resources such as health insurance, are also project goals.

Patients enrolled in the project will receive support in self-management prior to being discharged.

People are eligible to participate in the project if they do not have a regular primary care physician and if they have one or more of the following diseases:

• diabetes
• cardiovascular disease
• respiratory disease
• HIV, and
• sickle cell disease.

“Our goal is to extend the attention and care that patients receive from us beyond the four walls of UMDNJ-The University Hospital, thereby improving patient outcomes,” said David Bleich, MD, a project co-director.

The “I CARE-4-Healthcare Transition Project” will be implemented in partnership with the Visiting Nurse Association Health Group.

The project will be supported by a $300,000 grant from the Robert Wood Johnson Foundation‘s New Jersey Health Initiatives program with additional funding from the Healthcare Foundation of New Jersey.

More from Program Co-Director Melissa Scollan-Koliopoulos

Dr. Scollan-Koliopoulos explained to PHI the crucial role home health aides will play in the re-hospitalization prevention teams:

Home health aides were selected as the first tier because they are accustomed to the home and community environment in which patients manage their chronic illness on a day-to-day basis. Home health aides are trained and accustomed to observing and reporting symptoms to nurses, reinforcing health education, and motivating patients to comply with their care plans. They are also instrumental in helping patients obtain resources, such as food and items needed from pharmacies.

Home health aides close the gap on the disparity in educational status between nurses, physicians, and patients, which sometimes leads to miscommunication. This perspective is helpful when we are trying to improve health literacy. Sometimes, the home health aide will say, “What does that mean, doctor?” or, “Explain again what I need to tell the patient exactly” — making the higher-educated prescriber step back and say, “Wait a minute. I am speaking in Latin terms again!”

— by Deane Beebe