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 among the 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 & outpatient), home infusion of intravenous medications, 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 2016:

  • Nearly 18,000 medication reconciliations
  • More than 8,000 discharge counseling sessions
  • More than 9,000 medication histories
  • In excess of 3,500 transition of care activities
  • Greater than 2,000 anticoagulant discharge counseling sessions
  • 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 re-admission to the hospital.
  • Expansion of medication reconciliation pharmacy technicians from our Monmouth Medical Center pilot program to additional positions at Saint Barnabas Medical Center
  • To help expedite discharge of our patients from the Acute Care Facilities, the Retail Pharmacy Network Division’s delivery service to patient’s homes after the discharge prescriptions are processed continues its strong success. This service provided more than 499 home deliveries representing 1,274 prescriptions.
  • Established a compliance program for HIV patients within the Jersey City Medical Center Retail Pharmacy
  • The Retail Pharmacy Network successfully implemented a “Meds to Beds” Program. This service receives our patient’s discharge prescription then fills them and delivers the medications to the bedside prior to be discharged from one of our facilities. In 2016 this service processed 11,539 prescriptions for 4,524 patients.
  • Our Qualitas Home Infusion Division nursing colleagues performed more than 18,000 home infusion visits.
  • Our Pharmacy Team is extending their service outside the Acute Care Service Line to physician office practice and clinics. In 2016 more than 3,500 activities in this practice setting were completed.