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Saint Peter’s University Hospital plans to apply for funding from New Jersey’s Delivery System Reform Incentive Payment Program (DSRIP). DSRIP is one component of the state’s Comprehensive Medicaid Waiver as approved by the Centers for Medicare and Medicaid Services (CMS). It is a demonstration program designed to result in better care for individuals (including access to care, quality of care, and health outcomes), better health for the population, and lower costs by transitioning hospital funding to a model where payment is contingent on achieving health improvement goals and benchmarks.
The joint Community Health Needs Assessment, conducted by Saint Peter’s University Hospital and Robert Wood Johnson University Hospital, along with community partners, demonstrated that diabetes and hypertension are two of the most prevalent health issues affecting the residents of central New Jersey. More than half (56.2 percent) of adults surveyed have been diagnosed with at least one chronic condition, and 30.8 percent have been diagnosed with high blood pressure. According to the assessment, diabetes is more prevalent in communities with a noted concentration of Latino, African-American and South Asian individuals. Diet, obesity, age, disease, stress, and even smoking are believed to contribute to the onset of diabetes.
In addition, approximately one-quarter of residents in the survey reported at least one major barrier to wanted care and more than half reported difficulty navigating the healthcare system.
Description of Our Proposed Project:
Saint Peter’s will develop and implement a patient centered medical home for patients with a high need and the uninsured or underinsured adult population diagnosed with diabetes mellitus and hypertension, resulting in an improved overall quality of care. Patients will be entered into the program via ambulatory care (outpatient) services, the emergency department, inpatient services, same-day service locations, and community health screenings conducted by hospital staff. The program will include: use of multi-therapeutic outpatient evidenced-based management; lifestyle modification, nutritional consultation, intensive hospital discharge planning, a dedicated patient navigation system, andimproved social services.
Care improvement will be accomplished through addressing both medical and social care needs in a comprehensive, holistic manner. Care team members will include physicians, advanced practice nurses, registered nurses, social workers/case managers, nutritionists, and transition coaches with care organized and coordinated to achieve our project outcomes.
Desired Project Outcomes:
Saint Peter’s will engage the community in achieving improved quality of care for these patients through continuing and enhancing partnerships with other healthcare providers to improve communication about the patient’s healthcare status.
Contact Marge Drozd, director of Community Mobile Health Services at Saint Peter’s Healthcare System, with comments about this project or for more information at 732-745-8600, ext. 6773.
© 2013 Saint Peter’s Healthcare System254 Easton Avenue, New Brunswick, NJ 08901