Population Management


Health Affairs Article on TC

Article in August 2013 issue of Health Affairs detailing impact of CCNC's transitional care efforts.

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Interim evaluation of Transitional Care program impact; presentation by Dr. Carlos Jackson to CCNC Network leadership and program staff; May 2012 (mp4, 35MB, 25:53)

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Program components and early outcomes for transitional care – January 2012

Article in January 2012 North Carolina Medical Journal that describes CCNC's transitional care program components, early outcomes, and future challenges.

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Transitional Support

Managing transition from inpatient care

Community Care’s statewide approach is based on elements from the work of Eric Coleman, Mary Naylor, and others. Our 14 networks have crafted local solutions targeted to local circumstances.

Initially, CCNC’s transitional care efforts focused on the Aged, Blind, and Disabled (ABD) category of Medicaid recipients. While this group represents only about 30% of the population, they generate about 70% of the health care cost due to their complex chronic conditions.  Success with reducing this group’s overall hospital and ED utilization has paved the way for CCNC to provide transitional care for additional populations, such as high risk/high cost individuals and those dually-eligible for Medicaid and Medicare. CCNC plans in the future to expand transitional care efforts further to address the needs of the Medicare-only population and individuals covered by private insurers.

Key elements of CCNC’s approach

  • Health IT
    Electronic links with almost all the hospitals in the state, allowing receipt of timely information about Medicaid patients in the hospital and ED
  • Embedded staff
    Having Nurse Care Managers, Pharmacists and Behavioral Health Coordinators in hospitals that discharge a significant volume of Medicaid patients allows for interaction with the hospital team (Hospitalists, Discharge Planning, Pharmacy, Palliative Care, etc.)to facilitate optimal hospital stay. This includes discharge planning at the time of admission; the opportunity to visit the patient at the bedside to begin engagement; and putting processes in place for a smooth and timely discharge.
  • Home visits for high risk patients
    Patients at high-risk for a failed transition receive a home visit within 3 days of discharge with medication management, beginning with “medication reconciliation.” Often this is a team approach by a nurse care manager, pharmacist and primary care physician. Multiple medication lists (PCP record, hospital discharge meds, prescriptions from specialist and mental health providers, etc.) are gathered and combined with a “brown bag” assessment in attempt to provide a consolidated medication regimen that is therapeutic, cost-effective, and clear to the patient.
  • Red flags
    Patient and family education focuses on “red flags” that indicate a need to call the doctor, care manager, or in-home service provider.
  • Motivational interviewing
    Care Managers are trained in Motivational Interviewing techniques and encouraged to use evidence-based strategies such as “Teach Back”and referrals to Stanford Model of Chronic Disease Self-Management Program.
  • Patient notebook
    Patients are provided a CCNC Self-Management Notebook which serves as a personal health record and communication tool with primary care and specialty providers.
  • Prompt discharge follow-up
    Care Managers ensure patients have a follow-up appointment with their medical home, soon after discharge and that the patient attends the appointment. Many medical homes have embedded care managers that are able to schedule appointments as well as attend with the patient as needed.
  • CCNC Provider Portal
    Medical Homes can access data at the point-of-care regarding medications, services by other providers and potential gaps in care.
  • Community integration
    We cultivate existing relationships with a variety of community agencies and safety net providers, and continually pursue new relationships. Our partners include LME’s, mental health providers, home-health and hospice organizations, etc. Care Managers work with these agencies to coordinate care, share data, and avoid duplication of services.
  • Feedback to the medical home
    CCNC Care Managers provide timely information to the primary care doctor/medical home about hospitalizations, medications prescribed, social and environmental concerns, and other agencies providing services to our Medicaid patients (such as PCS, home health, mental health).
  • Identifying impactable patients
    Network quality improvement teams work with practices to help them identify their patients with frequent non-emergent ED use, multiple prescriptions fills for narcotics, and potentially preventable outpatient services.
  • Partnerships in care transitions
    Strong relationships exist at the state and local level with multiple agencies such as primary care and specialty providers, hospitals, Division of Aging, Health Departments, Division of Social Services, Home Health and Hospice, LME’s and mental health providers, AHEC/Improving Performance In Practices, etc.
  • Embedded care managers
    Many hospitals, LME’s, and Medical Homes have partnered with CCNC to have care managers embedded in their facility. The over arching goal of these partnerships is to coordinate care in effort to better meet patients needs without duplication of services and ensure deliver of high quality, cost-effective care across settings.
  • Reducing hospital readmissions
    Reducing potentially-preventable readmissions through enhanced transitional care is a priority for CCNC networks. Using risk-adjusted methodology, CCNC is also targeting patients with chronic conditions whose health care cost on potentially preventable hospital services (in-patient and ED) are higher than expected for patients of the same risk category. These patients often require more intense care management services for a longer period of time, as well as careful investigation and coordination of care when multiple services are in place.
  • PCMH support
    CCNC is also working with primary care practices to achieve Patient Centered Medical Home certification and/or to establish and implement workflows that will improve follow-up care for patients hospitalized, as well as better overall care from a consistent medical home.

Lessons learned in improving care transitions

Critical elements of programs to manage care transitions include:

  • Access to real-time hospital data allows us to know who is in the hospital, access these patients’ medical records, and to visit the patient at the bedside. Close participation in discharge planning is imperative.
  • Hospital-embedded Care Manager/Pharmacist teams establish relationships with patients and begin medication reconciliation as early as possible.
  • Bedside visits and participation in discharge planning by CCNC Behavioral Health Coordinators has improved behavioral linkage and follow-up upon discharge.
  • Home visits are extremely valuable and the best setting for medication reconciliation/medication management education. Additionally, the home visit provides optimal opportunity for a comprehensive assessment of the patient, their environment, and family dynamics, all of which are key to developing an effective patient-centered plan.
  • Several networks have forged partnerships with home health agencies for better coordination of care and have established workflows to include a “warm hand-off” approach when home health is ready to discharge.
  • Collaboration of Network Pharmacists, Behavioral Health Coordinators and Palliative Care Coordinators as part of a team greatly improves the management of transitions.