How we coordinate with the RWJUH discharge team

Robert Wood Johnson University Hospital is the RWJBarnabas Health academic flagship on French Street in New Brunswick, and its case management office runs on a predictable rhythm. Discharge rounds happen between 9 and 11 am Monday through Friday. By late morning, the floor social worker calls the family with a target discharge date, usually 24 to 48 hours out. That phone call is the right moment to loop us in.

According to 24 Hour Home Care NJ, the fastest path is a three-way conversation between the family, the RWJUH case manager, and Sofia Elmer, RN. Sofia reads the discharge summary, confirms the mobility level, flags any new medications, and matches a CHHA whose home base is within a 20-minute drive of the family’s house. For a New Brunswick or Edison address, that’s usually a caregiver who already knows the Route 1 and Route 18 patterns.

If the hospital is routing to rehab first, we still stay on the call. A start date is held for the week the family expects to come home, so the handoff from JFK Johnson Rehab in Edison or JAG Physical Therapy back to the house doesn’t drop into a gap.

RWJ service lines we staff behind

Robert Wood Johnson University Hospital runs five service lines that produce most of our home care starts: cardiac surgery, the Rutgers Cancer Institute of New Jersey, Level I trauma, the Comprehensive Stroke Center, and transplant. Each line has a different post-discharge rhythm.

Cardiac patients, especially after a CABG or valve replacement at RWJUH, come home with sternal precautions for six weeks. They can’t push, pull, or lift more than 10 pounds, which means they can’t lift a laundry basket or open the fridge one-handed with a grocery bag. A caregiver covers morning meds, breakfast, a short walk, and dinner prep, with shifts scheduled around the cardiology follow-up on French Street.

According to 24 Hour Home Care NJ, oncology discharges from the Rutgers Cancer Institute run two patterns: short-stay between chemo cycles, or longer-stay on comfort-focused care. The first gets lighter companion coverage; the second gets a CHHA who’s done end-stage work before, coordinated with the hospice RN. Call (908) 912-6342 once the oncologist confirms the discharge date.

Comprehensive Stroke Center discharges usually route through inpatient rehab before home. Trauma discharges from the Level I unit come with wound-care plans and mobility restrictions. Transplant discharges, especially kidney and liver, come with strict infection-prevention routines that a trained CHHA follows daily.

The 24 to 72 hour start window

Most RWJUH discharges give families less than 48 hours notice. According to 24 Hour Home Care NJ, that’s the number we build our Middlesex County intake process around. When Sofia takes the call, she asks for the discharge date, the home address, the mobility level, the medication list, and whether the house has a stair-free sleeping option. Those five answers tell her which caregiver on the roster is the right first match.

Within 24 hours we can usually staff an evening-only shift, which covers the first night. By the 48-hour mark a 12-hour day shift is possible. For 72 hours out, live-in or full 24-hour rotation is possible if the surgeon or hospitalist flagged fall risk or a parent living alone. Families in New Brunswick, Highland Park, and Edison have had start times in the four to six hour range. Our 24hourhomecarenj.com intake page lists the five intake questions in order.

Middlesex County towns we cover from this hospital

Our Middlesex County roster carries active CHHAs who live in or commute daily to New Brunswick, Highland Park, East Brunswick, Edison, Metuchen, Woodbridge, Piscataway, and South Plainfield. That eight-town band produces most Robert Wood Johnson University Hospital discharges, and it’s the band where we hit a 24-hour start window reliably.

Drive times matter along the Route 1 corridor. We pre-match caregivers who already run that route so a weather day doesn’t become a staffing miss. For Woodbridge and Metuchen, Garden State Parkway and Route 287 traffic shapes the schedule, so morning shifts start at 7 am. Highland Park families sit closest to the hospital, often a five-minute drive across the Raritan River. More detail is on the Middlesex County home care page or the home care after hospital discharge NJ guide.

When RWJ routes to JFK Johnson or JAG first

Robert Wood Johnson University Hospital sends many stroke, orthopedic, and spinal cord patients to JFK Johnson Rehabilitation Institute in Edison before home. JFK Johnson stays run two to four weeks on average, and the discharge from JFK is harder for families to plan because the hospital stay feels distant by the time it ends.

We watch for the JFK Johnson discharge date the same way we watch RWJUH’s. The social worker at JFK gives a target date in the final week. Post-stroke patients get a CHHA with prior post-stroke experience, and we coordinate with home PT and OT, including JAG Physical Therapy if the family picks a JAG clinic for outpatient follow-up. The post-stroke home care NJ guide walks through the first 30 days.

For dementia patients who go RWJUH to JFK Johnson to home, we often add overnight coverage from day one. Sleep patterns shift during a rehab stay, and the first week back home is when wandering risk peaks. The dementia home care NJ page has more detail.

What families pay and how insurance fits

Rates in 2026 run $30 per hour and up for companion visits, $400 to $550 per day for live-in care, and $720 to $1,080 per day for 24-hour rotation with two caregivers trading 12-hour shifts. Rate depends on the care plan, not the diagnosis. A live-in rate for a stable post-op patient reads differently than a 24-hour rotation for a parent with advanced dementia and a fall history.

Payment is private pay and private long-term care insurance only. We do not accept Medicaid or Medicare. Billing goes directly against John Hancock, Genworth, MetLife, Transamerica, and Mutual of Omaha policies, and we file the daily log sheets the insurer requires. Veterans may qualify for VA Aid and Attendance. The National Institute on Aging guide to long-term care explains how private policies fit alongside Medicare’s limited home-health benefit.

Call (908) 912-6342 for a 2026 rate quote for your specific Middlesex County address and shift pattern. The quote is same-day. For a quick preview, families often start with the NJ home care cost calculator.

For the full state-level overview of what post-discharge coverage looks like, our money page is 24-Hour Home Care in New Jersey · Hospital-Discharge Specialists. It walks through staffing patterns county by county, including Middlesex, Union, Somerset, and Essex.

Frequently asked questions