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 2020:

  • Excess of 29,000 medication reconciliations
  • More than 1,600 discharge counseling sessions
  • More than 4,400 medication histories
  • In excess of 4,000 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 2020, more than 7,800 activities in the physician practice setting were completed
  • We continued our initiative at Saint Barnabas Medical Center where a pharmacist accompanies a nurse to perform home visits to ensure compliance with medications in order to prevent admission and readmission to the hospital
  • Retail pharmacy Network Division’s delivery service to patient’s homes provided more than 141 deliveries representing 353 prescriptions
  • The Meds to Beds program processed 5,854 prescriptions for 11,773 patients
  • Our Qualitas Home Infusion Division nursing colleagues performed more than 24,446 home infusion visits
  • Qualitas Home Infusion provided 458 hydration only visits on behalf of CINJ and RWJ New Brunswick, generating an additional $318,353 revenue opportunity
  • More than 9,000 ambulatory activities performed by a pharmacist