Grant Awarded to JFCS by Janssen to support partnership program with Robert Wood Johnson University Hospital Hamilton

In April 2019, Robert Wood Johnson University Hospital Hamilton (RWJ) launched Healthy Lives Hamilton, a program designed to improve quality of life for those living with heart failure. Through a generous grant by Janssen Pharmaceuticals, JFCS is now teaming up with RWJ to bring our geriatric care management skills to offer Healthy Lives Hamilton Plus.

Studies have shown that providing home visits and early intervention upon discharge for patients with a diagnosis of heart failure have significantly lowered the risk of readmission. JFCS will provide the services of a geriatric care manager to discharged RWJ heart failure patients. Our care manager and a registered nurse will assess the patients in their homes within 24-72 hours post discharge.

The home visit allows the care team to provide health literacy skills so the patient and caregiver may better understand basic health information and services to make informed health decisions. These include medication usage, side effects and discharge instructions. A home visit also allows the RN to gather information firsthand about which medications are being taken regularly, and to better identify barriers to medication compliance or exacerbating factors such as high sodium foods in the kitchen. The goals of these initial visits are to increase adherence to the discharge plan, compliance with the new medication regimen, and identify resources that are needed including home care, medical equipment and/or assistive devices.

Our care manager will assess for activities of daily living, safety, transportation, and the level of caregiver support. Equipping patients with the necessary education and tools at home allows for the early detection of avoidable problems, improving their quality of life and reducing the likelihood of readmission.