Care Transition Program
Hunterdon Health has received funding from the Rural Health Transformation Grant to launch a new Care Transitions initiative. This program utilizes Community Health Workers (CHWs) to help patients connect with vital community resources. The Care Transition program focuses on preventing hospital readmissions by helping patients address specific social determinants of health.
The Care Coordination team, along with Nursing, will evaluate patients for many Social Determinants of Health (SDOH), including food insecurity, transportation, housing, and personal safety. If a patient triggers one of these SDOH indicators, they can and should be referred to a CHW to assess and offer resources.
CHWs are non-clinical employees who will conduct a brief "meet and greet" at the bedside or follow up with the patient after discharge. Within approximately 72 hours of discharge, they will assist with resources such as access to food pantries, transportation, medication access programs, or support groups to reduce social isolation. They may also provide appointment reminders and assistance in scheduling, but not for emergent care.
Several Community Health Workers and one Program Coordinator have been brought on to fulfill this program. By connecting patients and community resources and programs specific to their needs, the Care Transition Program aims to improve the health and well-being of our patients.
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