Population Management

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Medical Home

There is increasing national awareness of medical errors and quality deficiencies that occur during transitions in care.  The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is one nationally-recognized organization that has increased its focus on coordination of care after hospitalization. The Institute of Medicine (IOM) is also addressing strategies that may improve outcomes for patients as they transition from one setting to another, and advocates health care models that are patient-centric and collaborative. CCNC strives to address these issues through the implementation of a transitional support program that promotes safety and improved quality of care for our recipients as they move between care settings.

CCNC networks recognize that many of our patients with chronic illness(es) often require care from a variety of providers in multiple settings. Our goal with implementation of a transitional support process is to focus on patients moving from an inpatient setting to home or to an intermediate care or rehabilitation facility.

Our transitional program has major components adapted from the Care Transitions model developed by Eric A. Coleman, MD, MPH, Associate Professor at the Divisions of Health Care Policy and Research and Geriatric Medicine at the University of Colorado Health Sciences Center.

The CCNC model targets Aged, Blind, and Disabled (ABD) and chronically ill patients with complex care needs who meet CCNC screening criteria for intensive Chronic Care Management services. It is anticipated that these patients would require care in multiple settings.  We have developed a Standardized Care Management process to provide critical interventions that empower the patient/caregiver with self-management skills.  The ultimate goals for all CCNC Transitional programs are to promote better health outcomes for our patients and to decrease utilization of inpatient and emergency department services through focused Care Management interventions.

The major components of the CCNC Transitional Care Model emphasize the following interventions:

  1. Face-to-Face Contact with the Patient During Inpatient Admission - Our networks strive to meet and establish rapport with the patient during their admission and assist with the discharge planning process by ensuring that ordered treatments are communicated to providers who will care for the patient after discharge.
  2. Medication Reconciliation - Probably the most critical component of ensuring a safe transition, our Care Managers are tasked with engaging the patient/caregiver during a home visit or similar face-to-face encounter within 3 days of discharge.  The main objective for this contact is to reconcile discharge medication orders with medications ordered by the patient’s primary care provider (PCP), specialists, and with the medications the patient is actually taking in the home setting.
  3. Patient Self-Management and Education – This is achieved through patient education that revolves around realistic goals set by the patient and by encouraging the patient and/or caregiver to be an active participant in maintaining their health.  CCNC has developed a Self-Management Notebook (SMN) to facilitate communication between the patient and their healthcare providers and to assist in continuity of care across provider settings. Another primary goal of education is to ensure that the patient understands “red flag” symptoms to monitor, what to do if they occur, and when the PCP should be called.
  4. Facilitating Appropriate Follow-Up Care - One of the primary goals of this transitional component is to encourage the patient to keep all follow-up appointments and to re-link the patient with their PCP after a hospital discharge.


Interested in starting your own medical home program?  Get the nuts-and-bolts of the process at CCNC's Toolkit site.