Mobile Intergraded Healthcare Systems (MIHS) Community Healthcare Practitioners (CHiPs) monitor patients at home in the Trinitas post-discharge program for congestive heart failure patients. At right, Brant Maslowski, MICP, Mobile ICU Coordinator, visit Angelo Stazzella of Elizabeth to check his blood pressure while Rod Muench RN, MPA, MICP, Director of Pre-Hospital Services, reviews the patient’s medications. They are among several Trinitas ChiPs team members who visit patients to evaluate their nutrition, their overall health, and listen to concerns about their progress in order to determine if additional post-discharge care is needed.

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Doug Harris

Yolanda Fleming

Innovative program uses highly trained staff for prevention efforts

Trinitas Regional Medical Center has initiated an innovative program to reduce the risk of hospital readmission among patients being treated for heart failure. As a result, among the core group of cardiac patients involved in the program, 30-day readmissions have been cut to just 12 percent.

Through a multidisciplinary approach, healthcare professionals at Trinitas use their skills to prevent return visits of heart failure patients to the hospital. Mobile Intergraded Healthcare Systems (MIHS) Community Healthcare Practitioners (CHiPs), advanced practice nurses (APN), and EMT trained dispatchers are a team who intervene with heart failure patients. Working under the supervision of an emergency physician and a primary care physician, the team delivers patient education and other services to post-discharge heart failure patients in Elizabeth.

Data shows that residents of Elizabeth experience higher rates of cardiovascular disease, higher than those throughout the state and around the nation. "Since research showed the high percentage of readmission rates in our patient population, we wanted to use our expertise to bring those rates down," said Joseph McTernan, Senior Director of Clinical and Community Services. "Our post-discharge program for heart failure patients plays a major role in our overall plan to help residents in Elizabeth gain greater access to care, manage their medications more effectively, improve their health literacy, and gain a further understanding of how lifestyle changes can lead to better health."

Team members review patient medical records and schedule patients visits following hospitalization. When CHiPs visit, they assess patient diet and nutrition, home conditions, and other factors that might contribute to a readmission. Partnerships with community agencies and visiting nurse organizations are also part of the program. Working with a local food bank, Trinitas is also able to provide heart failure patients with a week’s worth of healthy frozen meals.

"In a short amount of time, we’ve seen a dramatic improvement in the hospital’s readmission rates that can frequently occur among heart failure patients," notes Gary S. Horan, President and Chief Executive Officer. "Teamwork within our organization and with outside partners has been cost effective, but more importantly, an avenue to improved cardiac health among patients vulnerable to re-hospitalization associated with heart failure."


About Trinitas Regional Medical Center
Trinitas Regional Medical Center (TRMC), a major center for comprehensive health services for those who live and work in Central New Jersey, is a Catholic teaching medical center sponsored by the Sisters of Charity of Saint Elizabeth in partnership with Elizabethtown Healthcare Foundation. With 10 Centers of Excellence across the continuum of care, Trinitas has distinguished itself in cardiology, cancer care, behavioral health, renal care, nursing education, diabetes management, wound healing and sleep medicine.

Posted: October 2, 2015

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