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Matheny Receives RWJF Grant to Improve Acute Care Hospital Transfers

Jeanne Lavelle, RN, center, is the new transitional
nurse, shown here conferring with Lisa McKenna,
RN, left, and Dr. Surbparkash Singh, staff

Matheny  has received a $300,000 grant from the  Robert Wood Johnson Foundation through its New Jersey Health Initiatives program to develop, implement and test a model for improving the quality of transitional care for persons with chronic health issues and medical complexities associated with developmental disabilities.  Matheny’s partners in this project are Morristown Medical Center in Morristown, NJ, and the Robert Wood Johnson University Hospital in New Brunswick, NJ.

While the majority of Matheny’s patients have cerebral palsy as their primary diagnosis, the medical complexities of Matheny patients have increased over the years.  Matheny patients have a long list of associated medical conditions such as vision and hearing deficits, seizure disorders, mental retardation and dysphagia, with resulting aspiration problems.  Because of these medical complexities, the transition to and from acute care hospitals is a difficult one.  Often, acute care staff members are not familiar with the patients, and they are not well-prepared to address all of their complex needs, particularly as the patients make the transition into the hospital and then back to Matheny or another setting. 

Over the past several years, Matheny has developed two primary mechanisms to help acute care staff members understand and address these patients’ needs better: 

  • A "trip nurse."
  • A mini medical record. 

The RWJF grant will enable Matheny to partner with Morristown Medical Center and Robert Wood Johnson University Hospital to formalize those two mechanisms and provide an unusual degree of interaction between Matheny staff and acute care hospital staff through the establishment of a nursing position dedicated just to the transition process.  These two acute care hospitals were selected for this project because they treat the majority of Matheny patients who require acute care hospitalization.  Grant funds have allowed Matheny to hire a full-time transitional nurse, Jeanne Lavelle, RN, who will accompany patients transported to these two acute care hospitals, encourage full and effective use of information in the patients’ “mini-record”, follow the patients throughout their hospitalization to facilitate discharge planning and foster development of resources needed for appropriate inpatient care and effective post-hospital transition. 

The project’s goal is to reduce the number of hospital readmissions of patients with developmental disabilities.  A Medicare Payment Advisory Commission (MedPAC) analysis of 2005 data found that 11.3% of Medicare recipients with a hospital admission were readmitted within 15 days of discharge, and 17.6% were readmitted within 30 days of discharge.  Seventy six percent of those readmissions within a 30-day period were determined to be potentially preventable.

In evaluating the results of this project, Matheny’s Institute for Research in Developmental Disabilities will examine the length of time between hospitalizations, numbers of re-hospitalizations and number of emergency room visits in the target population during the course of the project.  That data will be compared with data derived from clinical records of persons served in the 12 months preceding the project. 

Communication on a day-to-day basis between Matheny and the staff at the participating acute care hospitals will be managed by the transition nurse.  Key Matheny personnel at the administration level are:  Dr. Gary Eddey, chief medical officer, and Cathy Church, RN, director of nursing services.  Primary contacts at Morristown Medical Center are:  Dr. Stanley Fiel, chair of the department of medicine, and Trish O’Keefe, RN, director of nursing and acute care services.  At Robert Wood Johnson University Hospital, the primary contact is Dr. Alfred Tallia, chair, department of family medicine.

The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country.  As the nation’s largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change.  For more than 35 years, the Foundation has brought experience, commitment and a rigorous, balanced approach to the problems that affect the health and health care of those it serves.  When it comes to helping Americans lead healthier lives and get the care they need – the Foundation expects to make a difference in your lifetime.  For more information, visit

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