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University Hospital

UH to develop heart failure transition program for DSRIP

University Hospital plans to apply for funding from the New Jersey Delivery System Reform Incentive Payment (DSRIP) Program. DSRIP is part of New Jersey's Comprehensive Medicaid Waiver as approved by the US Centers for Medicare and Medicaid Services. It is a demonstration program that is designed to improve healthcare for individuals and improve the health of the population we serve.

NJ hospitals will be eligible to receive funding by implementing quality initiatives within their community and achieving improved clinical outcome results demonstrating the initiatives' impact on improving the New Jersey health care system.

University Hospital’s Community Need

The cardiovascular disease burden on the American people is immense. Major cardiovascular disease is the leading cause of death in the US. Annually, more than 770,000 Americans die from these diseases, including heart disease and stroke, with costs of 312 billion dollars per year. Heart disease costs Americans 195 billion dollars annually. There are over 5 million cases of heart failure reported in the US today. [1] (See Figure 1)

Nationwide, 16.8 people per thousand are admitted to the hospital for heart failure. In Essex County NJ, where University Hospital sits in Newark, the County Seat, the rate of hospitalization is 29% higher at 21.7 per thousand. The heart failure death rate for Essex County residents is 148.3/100,000 people. [3] (See Figures 2-4)

University Hospital has committed to developing the Heart Failure Transition Program to improve the quality of care for our heart failure patients, reduce heart failure admissions to the hospital, reduce hospital readmissions, and increase our patients’ satisfaction with their care.    This project was selected because we believe we can improve the quality of care for our patients while reducing costs and improving satisfaction.

University Hospital’s Heart Failure Transition Program

Our goal is to develop a comprehensive, patient centered heart failure center for our patients. We will be using evidence based quality improvement strategies that will enhance our ability to identify and address our heart failure patients’ needs in both the inpatient and outpatient environments. Using proven tools such as the Project 8Ps discharge risk assessment we will strive to improve our patients’ discharge experience and prevent readmissions.

Medication safety is of the utmost importance for our heart failure patients who are usually on a complex regimen at home. We will develop and implement a pharmacist led medication safety program in both the heart failure outpatient center and during our patients’ inpatient experience.

The experience at University Hospital will be improved through the use of a patient navigator and care coordinator specifically trained to meet the special needs of our heart failure patients.

Through specially designed heart failure educational experiences and a heart failure support group, patients will learn how to better manage their disease and adapt to the changes that they may be experiencing due to heart failure.

It is our sincere hope that through this innovative transition program our heart failure patients will receive safe, effective, patient centered and timely clinical care at University Hospital.


  1. Agency for Healthcare Research and Quality. (2013) National Healthcare Disparities Report 2012. AHRQ Publication No. 13-0003.
  2. Centers for Disease Control and Prevention. (2013)
  3. Centers for Disease Control and Prevention. (2013)

Figure 1

Footnote #2

Figure 2

NJ Heart Failure Hospitalization Rate per 1,000 Medicare Beneficiaries, 65+, All Race, All Gender, 2008-2010

Race or Ethnicity

Heart Failure Hospitalization Rate per 1,000 Medicare Beneficiaries



All Race












Footnote #3

Figure 3

Essex County NJ Heart Failure Hospitalization Rate per 1,000 Medicare Beneficiaries, 65+, All Race, All Gender, 2008-2010



All Race








* Age-adjusted  

Footnote #3

Figure 4

Essex County NJ Heart Failure Death Rate per 100,000, 35+, All Race, All Gender, 2008-2010



All Race


Black (non-Hispanic)


White (non-Hispanic)




American Indian and Alaskan Native

Insufficient Data

Asian and Pacific Islander


Footnote #3

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