Community Care of North Carolina Finds Success With Transitional Care

Data show that lower-risk patients who received transitional care support are much less likely to benefit, DuBard noted. "So we have become much smarter about targeting that intervention to the people who are most likely to benefit -- and have found a very strong return on investment there," she said.

And the transitional care program isn't just about preventing 30-day readmissions. "What we're finding is we are altering the long-term trajectory for these patients," DuBard said. "We are reducing the chance of admission and repeated hospital admissions during the course of the coming year by getting very involved with the intensive support they need after that first hospital discharge."

Between 2008 and 2014, as CCNC rolled out its transitional care program, it saw a 10.3 percent decline in admission rates among Medicaid patients with multiple chronic conditions who were enrolled in this CCNC medical home model.

Specifically, North Carolina Medicaid recipients not enrolled in this CCNC medical home model have about 932 admissions for every 1,000 people with multiple chronic conditions. This is compared to 471 admissions per 1,000 complex patients enrolled in the CCNC program.

"So complex Medicaid patients outside the CCNC program are being admitted at almost twice the rate of those in the CCNC program," DuBard said. "Because of the scale of our program, with an average cost of admission of $8,100, this amounts to a total savings of $389 million in fiscal year 2014 alone."

DuBard said she is convinced CCNC is making a dramatic difference in this population.

"It's increasingly well-established what a difference the medical home model can make with access to care, receipt of preventive care services and quality of chronic disease care," she said. "The importance of this kind of medical home, longitudinal, comprehensive care model for patients with multiple chronic conditions and high risk of hospital admission and readmissions is clear to us. This is a population that really stands to benefit from the medical home model with these wrap-around support services."