The people behind Community Care — and how we are improving health services in our state
A community-based infrastructure to target patients and populations in need
Access to data to drive our success
Programs to anticipate and address specific patient needs
Materials to support providers
Transitions Across Settings & Providers Work Group
Strengthen partnership and collaboration
Objective: Strengthening hospital partnerships with CCNC and discovering other opportunities for collaboration to improve transitions, divert unnecessary hospital and emergency department use, and integrate home- and community-based options.
Work Group Co-leads: Sabrena Lea (DAAS), Trish Farnham (DMA)
- Strengthen hospitals partnerships with CCNC and engage hospitalists and discharge planners in transitional care
- Leverage and align efforts with other CMS funded transition and diversion initiatives
- Coordinate efforts with and incorporate lessons learned from the Patient-centered Discharge Project Grant and related transition initiatives underway in NC
- Integrate Money Follows the Person and transitions across settings & providers including nursing homes, adult care homes, and hospice, and integrate home and community-based options.
- Explore community linkage and support bundling practices in other states
- Align efforts with CCNC’s transitional care program and enhance efforts across provider settings
Next Meeting and Location
Work group meetings have been completed.
- Transitions from Acute Care to Community
- Transitions from Nursing Home to Other Long Term Settings and Transitions Among Providers
- Issues and Themes
- September 19, 2011
- October 24, 2011
- Agenda December 16, 2011
- Responses to Questions