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
New demonstrations, pilots and programs
Materials to support providers
Telephonic Support Program
In November 2011, CCNC established a call center to support its fourteen local networks’ goals and initiatives through telephonic patient contact. To achieve its primary goal of decreasing ER utilization, the Call Center uses real-time hospital data to identify and contact patients who are linked to a CCNC provider who have a non-emergent visit to the ED. Through these calls, the Call Center staff emphasizes the importance of using the medical home and identifies any needed follow up or links to local resources within the patient’s community. While most of these calls are made to the patient only once, RNs in the Call Center attempt to call back a subset of the contacted patients who continue to over utilize the ED. The RNs assess these patient situations closely to identify gaps in care or new issues that can be referred to the networks for assistance.
The Call Center also provides information to newly enrolled CCNC patients on: appropriate ED use, urgent care utilization, available local resources, information specific to their medical home provider, co-pay for visits or prescriptions and how to access specialists. This patient education is provided primarily to patients who have been enrolled within the past 90 days, had an ED visit within the past 90 days and are currently classified as a CCNC priority patient. Future goals for this initiative include focusing these calls on all patients enrolled in the past 30 days.
Additionally, the Call Center offers health coaching to the CCNC Medicaid population. RNs who are also certified health coaches work with patients referred to them on wellness coaching and disease management coaching. Coaches use their experience and skills to motivate patients to accept responsibility as primary care taker of their own health and wellness by setting and reaching health related goals they set for themselves.
The Call Center makes more than 10, 000 call attempts each month. Data is collected on a number of items that can be shared with the networks and also with PCPs; for example, ”Did you call your PCP before going to the ED?”, “Did you know that your PCP has a 24 hour phone line?”, “Were you able to get your prescription filled?”. The data will hopefully be useful in improving access and communication to the medical home for patients.
As new programs emerge, as Medicaid and the networks continue to evolve and as new needs develop, the Call Center will continue to further define its processes to assure that staff is reaching patients who are most impactful.