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The GEM Unit is the latest in a host of initiatives taken by Monmouth to meet the special needs of its elderly patients.
 Monmouth Medical Center established comprehensive geriatric program coordinates health and social services for the elderly and their families with a focus on comprehensive care and education. Monmouth’s Anna Greenwall Geriatric Program specializes in medical care for the older adult, assessment of memory disorders and support for caregivers and the health professional, through a network of hospital-based and community-based services.
In addition, Monmouth Medical Center is the lead hospital in the Barnabas Health Transition Program for the Frail Elderly with Dementia, a program designed to improve patients’ self-management of their care and decrease hospital readmissions among this vulnerable population afflicted with multiple chronic health conditions. The program is funded through a Robert Wood-Johnson Foundation grant awarded to Barnabas Health Fondation.
The population of individuals 65 and older with dementia and other chronic conditions is at high risk for adverse health outcomes, hospital readmission and mortality. The Transition Program consists of eight core components to enhance care for this target population, including:
- Patient-Identified Goals and Activities
- Barrier and Support Resources Identification
- Patient and Caregiver Education
- Prescription Reconciliation and Education
- Multidisciplinary Case Conferencing
- Development of a Detailed, Patient-Specific “My Care Plan”
- “Receiving Provider” Notification
- Follow-up Care and Home Visits
Among the key objectives of the program are to screen 900 patients for frailty, dementia, and co-morbidities annually, to record patient-identified goals and objectives, identify barrier and support resources, conduct patient and caregiver education, conduct multidisciplinary case conferencing and develop a detailed, patient-specific My Care Plan for each patient. Through the program, Monmouth conducts follow-up calls and home visits through collaborating home health agencies.
Partnering with Barnabas Health is the Visiting Nurse Association of Central NJ, Care One at King James, HealthSouth Rehabilitation Hospital of Tinton Falls, and Aetna. Partners participate in multidisciplinary conferences and serve as liaisons to facilitate the implementation of the Transition Program as well as receive training and create protocols to implement and utilize the program’s core components to improve care.
RWJF’s New Jersey Health Initiatives program seeks to identify projects that present innovative strategies and collaborations to resolve health care needs in New Jersey communities. The grant awarded to Barnabas Health for the Transitions Program was among only nine projects out of 27 that were approved for funding in 2011.
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