Community Care of North Carolina Finds Success With Transitional Care

In 2008, state legislators and Medicaid administrators asked Community Care of North Carolina (CCNC), initially launched as a managed care program for the state's Medicaid recipients, to expand the system's scope of practice to integrate Medicaid's aged, blind and disabled recipients into its medical home model. Although this group represents only about 30 percent of the N.C. Medicaid population, it generates about 70 percent of the program's health care costs because of the patients' complex chronic conditions and related high hospitalization and readmission rates.

To address the issue, CCNC rolled out a population-based transitional care initiative(www.communitycarenc.org) aimed at helping these patients transition from the hospital back into their communities. Seven years later, the system prevents, on average, one readmission within the year for every six patients who receive this transitional care support.

"We recognized this time of transition after a hospital admission back home and into a normal routine of care was a very vulnerable time for patients," Annette DuBard, M.D., M.P.H., CCNC senior VP for informatics and evaluation, told AAFP News. "This is especially true in this modern era, when very frequently the primary care provider is not involved in the patient's inpatient care. A lot can happen that the primary care provider isn't in the loop on."

DuBard said patients often are discharged from the hospital with new medication regimens and have additional follow-up needs and diagnoses that require ongoing care. "So there's a real need for a systematic way to bridge patients back into a sustained plan of care," she said.