I-Care 4 Health Transitions: Improving Care for a Health Transition using a 4-Tiered Approach to Collaboration Across the Continuum

The I-Care 4 Health Transition project builds upon a successful Department of Medicine project that tested the effectiveness of a transitional care coordinator (APN with case management skills) in improving diabetes outcomes. Four levels of providers will co-manage chronic conditions across the continuum of care. Health literacy interventions will occur during the inpatient stay, with navigation through the healthcare system, and follow with transitional care by advanced practice nurses to prevent 30-day emergency department recidivism. The project is a collaboration among New Jersey Medical School, the Rutgers College of Nursing, and community providers (Visiting Nurse Association of Central NJ and Newark Community Health Center).