Programs and Communities

Disease burden is higher in the United States than in comparable countries. The Patient Self Determination Act of 1990 requires healthcare facilities to provide Advance Care Planning (ACP) information to all Medicare patients. The healthcare staffs’ (n=7) commitment to 3-days of ACP training increase ACP rates in the primary care setting. The Medicare Incentive Program is the platform for this initiative. This quantitative project used a valid and reliable pre and posttest design that consisted of 27 items on a Likert-scale. A 3.5-month chart audit (n=91) was conducted to assess the completion rate. Descriptive statistics was used to describe the demographic data.

The results of the two-tailed Wilcoxon signed rank test were significant based on an alpha value of 0.05, V = 0.00, z = -2.37, p = .018. There was a significant increase in the post-readiness to change average scores. A Mann Whitney test was used to analyze the statistically significant difference between the averages in two ACP types and electronic health record documentation (EHR). Staff did not always code (Mdn = 0.00) but they documented in the EHR (Mdn =1.00; 512.00, p = 0.003). ACP discussion was performed 63% of the time during Annual Wellness Visits (AWV), and there was a 49% increase in the EHR documentation. Trained staff are key stakeholders in guiding ACP conversations. They understand the barriers, impact, and consequences related to the lack of advance directives.

Ineffective transitional care programs for ensuring the continuation of care from acute settings to the home settings post discharge can result in rehospitalization of elderly patients with chronic diseases. Usually, transitional care should be time-sensitive, patient-centered services intended to ensure continuity of care and an efficient transition between health care settings or home. A patient centered transitional care program was implemented at an outpatient primary care facility to reduce readmission rates. Institutional Review Board approval was obtained.

Twenty adult patients with chronic diseases discharged from an acute setting were identified. A follow up phone call and/or a home visit within 24-72 hours post discharge was employed. The Care Transitions Measure (CTM®) and Medication Discrepancy Tool (MDT®) were utilized to identify quality of care of transition and medication discrepancies. A chart audit collected data on the age of participant, diagnosis for initial hospitalization, CTM score, home visit, and ED visits or re-hospitalizations after 30 days of discharge. The outcome indicated that transitional care within primary care utilizing evidence-based practices is beneficial in reducing readmission rates. A logistic regression showed model significance, p = .002, suggesting that the CTM score was effective for both telephone support (TS) and home visit (HV).

A correlation analysis showed that as age of participants increased, the CTM score decreased, indicating that older adults required more support. A significance p <.001, of a proportional test indicated that readmission rates after the intervention was lower. It is evident that providing a timely and effective transitional care intervention in a primary care setting can reduce hospital readmissions, improve symptom management and quality of life of adult patients with chronic diseases.

The New Jersey Childhood Obesity Study was designed to provide vital information for planning, implementing, and evaluating interventions aimed at preventing childhood obesity in five New Jersey municipalities: Camden, Newark, New Brunswick, Trenton, and Vineland. These five communities are being supported by the Robert Wood Johnson Foundation’s New Jersey Partnership for Healthy Kids program to plan and implement policy and environmental change strategies to prevent childhood obesity. Effective interventions for addressing childhood obesity require community-specific information on

who is most at risk and on contributing factors that can be addressed through tailored interventions that meet the needs of the community. Based on comprehensive research, a series of reports are being prepared for each community to assist in planning effective interventions.

The main components of the study were:

• A household telephone survey of 1700 families with 3–18 year old children,

• De-identified heights and weights measured at public schools,

• Assessment of the food and physical activity environments using objective data.

This report presents the results from the household survey. Reports based on school body mass index (BMI) data and food and physical activity environment data are available at www.cshp.rutgers.edu/childhoodobesity.htm.

The New Jersey Childhood Obesity Study was designed to provide vital information for planning, implementing, and evaluating interventions aimed at preventing childhood obesity in five New Jersey municipalities: Camden, Newark, New Brunswick, Trenton, and Vineland. These five communities are being supported by the Robert Wood Johnson Foundation’s New Jersey Partnership for Healthy Kids program to plan and implement policy and environmental change strategies to prevent childhood obesity. Effective interventions for addressing childhood obesity require community-specific information on

who is most at risk and on contributing factors that can be addressed through tailored interventions that meet the needs of the community. Based on comprehensive research, a series of reports are being prepared for each community to assist in planning effective interventions.

The main components of the study were:

• A household telephone survey of 1700 families with 3–18 year old children,

• De-identified heights and weights measured at public schools,

• Assessment of the food and physical activity environments using objective data.

This report presents the results from the household survey. Reports based on school body mass index (BMI) data and food and physical activity environment data are available at www.cshp.rutgers.edu/childhoodobesity.htm.

The maps in this chartbook describe the physical activity environment in Camden in terms of geographic distribution of parks and physical activity facilities. Research shows that people who have access to these facilities are more likely to be physically active.

• The maps in this chartbook were created using physical activity facilities data from a commercial database (lnfoUSA, 2008), data from city departments, as well as information obtained from systematic web searches. The maps present data for the city of Camden and for a 1 mile buffer area around Camden.

• Physical activity centers include private and public facilities which offer physical activity opportunities for children 3-18 years of age.

• Physical activity environment maps are compared with Census 2000 data to visualize accessibility of physical activity opportunities in neighborhoods with different characteristics.

• Poverty level presented in this chartbook are based on the 2000 Federal Poverty Guidelines.

• Crime rates in Camden are presented at the census block group level as relative crime risk (CrimeRisk) obtained from a commercial data source (Applied Geographic Solutions, 2008). CrimeRisk - an index value derived from modeling the relationship between crime rates and demographics data - is expressed as the risk of crime occurring in a specific block group relative to the national average. For this chartbook, data on total CrimeRisk, which includes personal and property crimes, are reported.

The maps in this chartbook describe the physical activity environment in New Brunswick in terms of geographic distribution of parks and physical activity facilities. Research shows that people who have access to these facilities are more likely to be physically active.

• The maps in this chartbook were created using physical activity facilities data from a commercial database (lnfoUSA, 2008), data from city departments, as well as information obtained from systematic web searches. The maps present data for the city of New Brunswick and for a 1 mile buffer area around New Brunswick.

• Physical activity centers include private and public facilities which offer physical activity opportunities for children 3-18 years of age.

• Physical activity environment maps are compared with Census 2000 data to visualize accessibility of physical activity opportunities in neighborhoods with different characteristics.

• Poverty level presented in this chartbook are based on the 2000 Federal Poverty Guidelines.

• Crime rates in New Brunswick are presented at the census block group level as relative crime risk (CrimeRisk) obtained from a commercial data source (Applied Geographic Solutions, 2008). CrimeRisk - an index value derived from modeling the relationship between crime rates and demographics data - is expressed as the risk of crime occurring in a specific block group relative to the national average. For this chartbook, data on total CrimeRisk, which includes personal and property crimes, are reported.

The New Jersey Childhood Obesity Study, funded by the Robert Wood Johnson Foundation, aims to provide vital information for planning, implementing and evaluating interventions aimed at preventing childhood obesity in five New Jersey municipalities: Camden, Newark, New Brunswick, Trenton, and Vineland. These five communities are being supported by RWJF's New Jersey Partnership for Healthy Kids program to plan and implement policy and environmental change strategies to prevent childhood obesity.

Effective interventions for addressing childhood obesity require community specific information on who is most at risk and on contributing factors that can be addressed through tailored interventions that meet the needs of the community.

Using a comprehensive research study, the Center for State Health Policy at Rutgers University is working collaboratively with the State Program Office for New Jersey Partnership for Healthy Kids and the five communities to address these information needs. The main components of the study include:

• A household survey of 1700 families with 3 -18 year old children

• De-identified heights and weights data from public school districts

• Assessment of the food and physical activity environments using objective data

Data books and maps based on the results of the study are being shared with the community coalitions in the five communities to help them plan their interventions.

The New Jersey Childhood Obesity Study, funded by the Robert Wood Johnson Foundation, aims to provide vital information for planning, implementing and evaluating interventions aimed at preventing childhood obesity in five ew Jersey municipalities: Camden, Newark, New Brunswick, Trenton, and Vineland. These five communities are being supported by RWJF's New Jersey Partnership for Healthy Kids program to plan and implement policy and environmental change strategies to prevent childhood obesity.

Effective interventions for addressing childhood obesity require community specific information on who is most at risk and on contributing factors that can be addressed through tailored interventions that meet the needs of the community.

Using a comprehensive research study, the Center for State Health Policy at Rutgers University is working collaboratively with the State Program Office for New Jersey Partnership for Healthy Kids and the five communities to address these information needs. The main components of the study include:

• A household survey of 1700 families with 3 -18 year old children

• De-identified heights and weights data from public school districts

• Assessment of the food and physical activity environments using objective data

Data books and maps based on the results of the study are being shared with the community coalitions in the five communities to help them plan their interventions.