Adolescent Mental Health

At One Health South Jersey, we specialize in optimizing the critical transition points between acute and post-acute care settings. Our consulting services address the fragmented nature of care delivery that leads to poor outcomes, unnecessary readmissions, and increased healthcare costs – particularly for vulnerable populations in New Jersey’s complex healthcare ecosystem.

The Current Landscape of Acute & Post-Acute Care in New Jersey

New Jersey faces unique challenges in care coordination:

• Readmission Rates: NJ hospitals experience a 15.2% all-cause 30-day readmission rate, higher than the national average (NJHA, 2023)
• Post-Acute Utilization: 35% of Medicare patients are discharged to post-acute facilities, but care coordination remains inconsistent (CMS, 2023)
• Disparities in Care: Low-income patients experience 22% higher readmission rates than higher-income patients (RWJF, 2023)
• Aging Population: With 16% of NJ residents over 65 (projected to grow to 20% by 2030), demand for coordinated post-acute services is increasing rapidly

Our Comprehensive Consulting Framework

• Acute Care Optimization

We help hospitals and health systems implement evidence-based strategies to:

• Standardize discharge planning processes through structured protocols and checklists that reduce variation in practice
• Enhance risk stratification using predictive analytics to identify high-risk patients needing intensive transition support
• Improve care team communication through structured handoff tools and interdisciplinary rounds
• Implement real-time discharge monitoring to identify and address bottlenecks in real time

Demonstrated Outcomes:

• 30-40% reduction in discharge delays
• 25% improvement in patient/family discharge education comprehension
• 20% decrease in medication reconciliation errors

1. Post-Acute Care Network Development

We assist organizations in building high-performing post-acute networks through:

• Standardized quality metrics across SNFs, home health agencies, and rehab facilities
• Shared clinical protocols that ensure continuity of care
• Performance-based contracting that incentivizes quality outcomes
• Technology-enabled care coordination platforms connecting acute and post-acute providers

Results Achieved:

• 35% reduction in variation in SNF length of stay
• 40% improvement in timely follow-up visits
• 28% decrease in preventable readmissions from SNFs

III. Transitional Care Programs

Our evidence-based transitional care models include:

• Nurse-led transition coaching programs that bridge hospital-to-home gaps
• Community health worker interventions addressing social determinants
• Pharmacist-led medication management post-discharge
• Remote patient monitoring for high-risk patients

Documented Impact:

• 45% reduction in 30-day readmissions for enrolled patients
• $2,800 average savings per patient in avoidable utilization
• 60% improvement in patient satisfaction with care transitions

1. Specialized Programs for High-Need Populations

We develop targeted approaches for:

• Medicare-Medicaid dual eligibles (representing 15% of NJ’s Medicare population)
• Patients with complex chronic conditions
• Behavioral health comorbidities
• Socially vulnerable populations

Program Outcomes:

• 50% reduction in ED visits for behavioral health crises
• 35% improvement in care plan adherence
• 40% increase in successful community reintegration

Why Our Approach Works

• New Jersey-Specific Expertise: Deep understanding of NJ’s regulatory environment and payer mix
• Health Equity Focus: Specialized approaches for vulnerable populations
• Proven Models: Adaptation of nationally recognized care transition frameworks
• Financial Viability: Solutions designed with sustainable reimbursement in mind

Case Study:  Care Transitions Initiative

Challenge: A safety-net hospital with 22% readmission rate for CHF patients

Our Interventions:

1. Implemented standardized discharge checklist
2. Created SNF preferred network with shared protocols
3. Deployed transition coaches for high-risk patients
4. Established post-discharge telehealth follow-up

Results:

• 38% reduction in 30-day readmissions
• $1.2 million annual cost savings
• 45% improvement in patient-reported care coordination

Partner With Us

Our acute and post-acute care consulting services can help your organization:

• Reduce preventable readmissions
• Improve care coordination across settings
• Enhance patient outcomes and experience
• Optimize post-acute network performance
• Achieve value-based care success