10:00-11:00 am
Room: 226 ABC North 

Improving Transitions of Care Through an Innovative Model Addressing Social Determinants
Presenters: Jenny J. Bernard, BSN MSN, and Victor A. Carrillo, PhD MPA

After attending this session, the participants will be able to: 1).identify gaps in care that can contribute to unplanned readmissions and poor transitions of care in underserved, low income, high- risk patients; 2). discuss how social determinants of health can negatively impact outcomes; 3). describe an innovative, evidence-based transitions of care model and its key interventions which address social disparities and improve outcomes; 4). list metrics required to track results and identify improvement opportunities; and 5). discuss methods to sustain improvement, both in health outcomes and program expansion.

Learning Objectives:

  • Apply best practices which address social determinants of health to create an effective transitions of care model for high-risk, low income patients
  • Develop strategic partnerships outside the hospital walls to improve population health and reduce disparities in healthcare
  • Learn how to use patient stories and the voice of the patient to share success and motivate others to create similar transitions of care programs
  • Identify metrics to track results and methods to sustain improvement

Jenny Bernard, Transitions of Care APN, is the founder of The First Thirty Program, a transitions of care heart strengthening program for cardiac patients. She has APN experience working in transitions of care, hospice home care, adult and geriatric urgent care. Bernard has 10 years of experience as a charge nurse at Hackensack University Medical Center in the organ transplant/urology unit. She earned her BSN and MSN from Rutgers University. She is medical surgical certified and the recipient of various awards, including Nursing Excellence Award for Innovation in 2016, Nursing Scholar Award for Research in 2016, and Outstanding Project Results 2015. Recent presentations include Strategies to Reduce Readmissions at the Premier's National Breakthrough Conference 2016 and 2017, The First 30 for a CMS project including 49 NJ hospitals and CMS, and for the Advance Practice Committee at Hackensack UMC.

In his role at Hackensack Meridian Health (HMH), Victor Carrillo works closely with the HMH executive team, hospital presidents, CMOs, department chairs, Population Health, and the Physician Enterprise to develop and lead the implementation of HMH system-wide inpatient & ambulatory quality initiative strategies. Dr. Carrillo is also responsible for oversight of the system-wide quality outcomes and Transitions of Care programs, and leads the identification, implementation, and execution of tactics to assure a high performing, patient-centric, network-wide health services. Prior to joining the Hackensack Meridian Health team, he served as Director, Community Health Development at NewYork-Presbyterian Hospital. In this position, he oversaw the development and implementation of various public health programs in the New York City area.

Audience Level: CPHQ/Mid
Topic: Population Health & Care Transitions
Date: September 16