I am nominating Karen Dipietro, transitions of care RN for RWJ Rahway. I have known Karen for the past four or five years since she began working on the CCTP grant and we have worked in a collaborative capacity to assist the patients of Rahway Hospital in the community. Karen is well respected within the hospital with doctors, case management and social work departments and patients. She is an exemplary RN who manages patients using the Eric Coleman model for Transitional care to coach the chronically ill population seen in Rahway with multiple comorbidities. She assists them and their caregivers to better manage their illnesses independently. She has taken her vast nursing knowledge and homecare experience and uses it to coordinate community resources, collaborate with VNA, MDs, and others in the community to assist and coach patients with their health and social needs.
Karen is often a bridge to care with patients who may not always fit the homecare model and has been indispensable in assisting the hospital with transitioning some of these hard to manage patients back home. One example was a challenging patient who did not fit the typical "transitions diagnosis" but was high risk for readmission. She was asked to see him because he went home without Gtube instructions and was missing all of his prescriptions. Karen went out on a Saturday before VNA with Gtube supplies and prescriptions to assist with meds and teaching and prevented a trip to the ED. Her dedication and success with these types of patients make her well deserving of this award.