Section: News

Queen’s CARE Network wins Robert Wood Johnson Foundation contest; demonstrates how better care transitions can prevent readmissions


Queen of the Valley's CARE Network (Case Management, Advocacy, Resource/Referral, Education) is one of five innovative programs to reduce potentially avoidable hospitalizations through better care transitions that are winners of the Robert Wood Johnson Foundation's (RWJF) "Transitions to Better Care" video contest.

Patients, families, nurses, care coordinators, and other front-line health care providers from across the country were invited to submit videos telling their stories of how they help patients make successful transitions out of the hospital. More than 100 videos were submitted showcasing innovative, patient-centered approaches at transition points in care.

The contest is part of Care About Your Care, a month-long effort sponsored by RWJF to focus attention on the national problem of people returning to the hospital soon after they are discharged.

Almost one in five elderly patients released from a hospital is back within 30 days and more than a third are back within 90 days. Many of these return visits could be avoided with better care transitions when a patient is discharged from the hospital.

"The CARE Network has been working with a broad network of community partners to create effective ways to reduce hospital readmissions and to build and strengthen shared accountability toward quality care in the Napa Valley for nearly 15 years," said Dana Codron, executive director , Community Outreach Department, Queen of the Valley Medical Center. "The RWJF deserves recognition for bringing heightened awareness to this topic and for bringing together representatives from across the country to help find solutions. We could not be more honored or more excited to be part of the conversation."

Codron, Queen of the Valley Medical Center President and CEO Walt Mickens, and CARE Network Coordinator Aura Silva will join Nancy Snyderman, MD, NBC News chief medical editor, and Risa Lavizzo-Mourey, MD, RWJF president and CEO, at a Care About Your Care event later this month in Washington, D.C., highlighting successful ways to improve care transitions and reduce avoidable hospital readmissions. They will receive special recognition from RWJF and a professionally produced video describing their innovation.

"These videos provide examples of how hospitals, doctors, nurses, and other providers across the country are developing innovative ways to improve care for patients," said Anne F. Weiss, team director and senior program officer at RWJF. "The contest winners, and all those who participated, should be proud of the important work they are doing to effectively coordinate care with their patients and other providers."

Other winners of the video contest are:

  • Cullman Regional Medical Center, Cullman, Ala. – A program called "Good to Go" ensures patients understand and comply with their discharge instructions by having caregivers record discharge sessions with their patients. The patient and family can listen to the captured conversation and ask questions to clarify confusion. Good to Go caregivers can also access instructional videos, baseline photos, appointment reminders, medication lists, and more from any phone or computer using secure login information.
  • Mercy Health, Cincinnati, Ohio – At Mercy Health, nurses developed a system to evaluate patients and work collaboratively with other health care providers to provide them with the appropriate care. The team helps patients take ownership of their situations to help prevent readmissions.
  • Northern Piedmont Community Care, Durham, N.C. – Northern Piedmont Community Care developed a community-based care management system that provides transitional care, chronic disease management, social work services, service coordination, access support, health education, and nutrition counseling. The program, which focuses on those who are frequent users of the hospital, offers support and links patients to primary care and other services they need.
  • University of Utah Health Care, Salt Lake City, Utah – The Health Care Transitions Program developed the Transition Navigator role to provide direct follow-through for complex patients being discharged from the hospital. The Transition Navigator communicates with the hospital and primary care teams to bridge the gap and ensure continuity of care. They work closely with patients to make certain they have a clear understanding of their plan and provide additional support through a personal care manager.

Submissions were evaluated on the quality of the story and method of ensuring safe transitions, potential for replication, and an element of engaging the patient in the hospital discharge process.

RWJF will convene dozens of national and grassroots organizations for a Care About Your Care event in Washington, D.C., to discuss how health care leaders in communities and hospitals can best coordinate care for patients leaving the hospital. The event will be simulcast live on Feb. 13 at 12:30 p.m. EST.

This is the second time the CARE Network has been recognized nationally for its work. In June, 2012, the American Hospital Association gave the program a prestigious AHA Nova Award. The award honors hospital-community collaborations that improve community health.

More About the CARE Network

  • The CARE Network (Case Management, Advocacy, Resource/Referral, Education) provides an interdisciplinary continuum of care from hospital to home followed by community-based chronic disease management support. The program works to improve health conditions and quality of life among patients and reduce health care costs through better coordination, continuity of care, timely enrollment, and access to public assistance programs and community services.

An interdisciplinary team comprised of registered nurses, social workers, community care aides, a behavioral health specialist and a chaplain provide comprehensive support and case management services to referred patients, including:

  • Disease education (including coping and decision-making)
  • Medication compliance and adherence
  • Benefits, financial and community resources
  • Limited social or family support
  • Home safety concerns
  • Over- or under-utilization of medical services

About the Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest philanthropy devoted exclusively to health and health care, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, measurable, and timely change. For 40 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime. Follow the Foundation on Twitter ( or Facebook (

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