Robert Wood Johnson Foundation Grant to Fund Princeton HealthCare System’s Partnerships for PIECE

Oct 11, 2011

Princeton HealthCare System (PHCS) has launched a two-year initiative to improve older adults' transition from the hospital to the community, funded by a $300,000 grant from the Robert Wood Johnson Foundation through its New Jersey Health Initiatives program.

The project - known as Partnerships for PIECE (Patient-Centered, Integrated Elder Care and Empowerment) - was one of nine to receive grant funding this year under the Foundation's New Jersey Health Initiatives 2011: Transitions in Care Program.

In addition to the $300,000 grant, the Laurie Foundation awarded PHCS $15,000 to further support the initiative.

Partnerships for PIECE will take a three-tiered approach: Training for nine skilled nursing facility partners on how to improve communication during a transition; utilizing a nurse practitioner to support patients transitioning to home; and implementing a data registry to streamline electronic communication.

The population served will consist of recently hospitalized patients, age 70 and older, with multiple chronic and acute diagnoses.

"This program is a key component in PHCS's larger vision to offer comprehensive geriatric care," said Kathleen Seneca, APN and PIECE Project Director. "We believe Partnerships for PIECE will make a real difference to our patients' health and well-being as they transition to home or to other healthcare facilities in the community."

PHCS is developing a comprehensive model for specialized continuing care of patients over the age of 65 to fully bridge inpatient and outpatient services under the leadership of a multidisciplinary Geriatric Steering Committee. Paving the way are two fully operational initiatives dedicated to the care of the vulnerable geriatric population: the NICHE (Nurses Improving Care for Health System Elders) Program and the ACE (Acute Care of the Elderly) Unit at the University Medical Center at Princeton. PHCS' new hospital in neighboring Plainsboro, scheduled to open in May 2012, will include a specialized geriatric area in the emergency department.

PHCS will use the modified POLST (Practitioner's Orders Concerning Life Sustaining Treatment) form to utilize the patient's goals of care as an organizing focal point across all levels of care.

New Jersey Goals of Care (, a non-profit organization dedicated to helping older adults meet their healthcare goals, is PHCS' primary partner in Partnerships for PIECE. Dr. David Barile, Executive Director and Chief Medical Officer of New Jersey Goals of Care, will provide expertise and leadership, especially in relation to partner training and consultation.

"The grant is of enormous importance for advancing the POLST initiative in New Jersey," said Dr. Barile, who also serves as Medical Director of the ACE Unit at University Medical Center at Princeton. "The POLST pilot that is attached to Partnerships for PIECE will be the largest in the region and will greatly assist physicians, the health care team and their patients as they transition across health care settings."

In addition to New Jersey Goals of Care, PHCS will partner with nine long-term-care skilled nursing facilities: Merwick, Meadow Lakes, Pavilions at Forrestal, Princeton Care Center, Monroe Village, Cranbury Center, The Elms of Cranbury, Stonebridge at Montgomery, and Park Place Center. These partners will participate in and benefit from consultation, training, continuing education, and ongoing performance improvement processes. All partners will be expected to share data in the patient registry.

"Participating in the PIECE project will yield improvements in the quality of care, and the quality of life for our elders," said Jay Zimmer, Executive Director of Meadow Lakes. "We should realize fewer readmissions to the hospital, a reduction in medical errors and vast, all-around improvement in communication among multiple care settings. We are very excited about being selected as a partner and look forward to enhancing our relationship with the University Medical Center of Princeton."

About University Medical Center at Princeton

A unit of Princeton HealthCare System, UMCP has earned recognition as one of the nation's Top Hospitals for patient safety and quality of care by The Leapfrog Group for three years in a row. UMCP is the only New Jersey hospital to earn that designation for three consecutive years. In 2010, The Leapfrog Group ranked UMCP #1 among New Jersey hospitals for overall safety and quality of care. Established in 1919, UMCP is a University Hospital Affiliate of the University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School and a Clinical Research Affiliate of The Cancer Institute of New Jersey. In July 2009, UMCP entered into a partnership with Children's Hospital of Philadelphia (CHOP) to enhance pediatric services available at the hospital through pediatric emergency consultation, inpatient pediatric care, and neonatal care. Princeton HealthCare System is building a state-of-the-art replacement hospital - named University Medical Center of Princeton at Plainsboro - that is scheduled to open in May 2012. For more information, visit

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 nearly 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. For more information, visit

About New Jersey Health Initiatives

New Jersey Health Initiatives (NJHI), a statewide grantmaking program of the Robert Wood Johnson Foundation (RWJF), supports innovative approaches to resolve health and health care needs in New Jersey. NJHI supports a wide range of community-based service implementation projects that correspond to RWJF's interest areas through competitive grants awarded annually. Projects focus on health services delivery, improvement in health, and the expansion of leadership expertise through grant making.