Care Continuum

The RWJBarnabas Health Foundational Care Continuum strategy is centered around Transitions of Care.

Transitions of Care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Locations include hospitals, sub-acute and post-acute nursing homes, the patient’s home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination amongst healthcare professionals involved in the transition. The Pharmacy Enterprise has engaged in several activities to aid in the health system’s overall strategy of Transitions of Care such as: patient medication counseling (inpatient and outpatient), home infusion of intravenous medications, and discharge medications filled and delivered to a patients bedside prior to discharge.

The team has increased its presence in the area of care continuum. The following care continuum activities were completed in 2023:

  • Excess of 20,555 medication reconciliations
  • More than 261 discharge counseling sessions
  • More than 12,739 medication histories
  • In excess of 203 transition of care activities
  • Our pharmacy team continued to extend their service outside of the Acute Care Service Line to physician office practices and clinics. In 2023, Embedded ambulatory care pharmacy specialists provided over 8100 medication encounters with more than 3450 individual patients
  • Retail Pharmacy Network Division’s delivery service to patient’s homes provided more than 705 deliveries representing 1,413 prescriptions
  • The Meds to Beds program processed 13,381 prescriptions for 5,403 patients
  • Our RWJBH Home Infusion Division nursing colleagues performed more than 24,707 home infusion visits
  • RWJBH Home Infusion provided 274 hydration only visits on behalf of CINJ and RWJ New Brunswick, generating an additional $197,408 revenue opportunity
  • More than 1,160 ambulatory activities performed by a pharmacist