A statewide effort under a North Carolina Community Care Networks (NCCCN), www.ccncares.com contract with the state Department of Health and Human Services, is addressing the needs of Medicaid patients with chronic conditions at high risk for repeat hospitalizations.
By targeting high risk patients and working with them to better manage their health, the NCCCN, a physician-led nonprofit, helps to manage care for 1.4 million Medicaid recipients. The program has been able to cut the rates of inpatient admissions and readmissions by 10 percent over the last six years for the specific Medicaid population with complex and chronic conditions.
NCCCN’s transitional care program includes:
- Performing real-time data exchange with North Carolina hospitals to notify them when Medicaid patients are admitted to the hospital
- Embedding nurse care managers and pharmacists in hospitals and primary care practices to work directly with the patient’s physicians and coordinate care across settings
- Visiting high-risk patients’ homes within three days of discharge to review medications, establish a comprehensive care plan, plus counsel patients and caregivers on how to identify warning signs, how to manage chronic conditions, and how to communicate with providers
- Identifying other patients at high-risk for hospital readmission that are most likely to benefit from care management
- Cultivating relationships with community agencies and local resources to coordinate care and avoid duplication of services
Another NCCCN program helps patients with Sickle Cell Disorder (SCD) to receive better care when they come to the Emergency Department. The Sickle Cell initiative builds on collaboration with pediatrics, specialists, behavioral health professionals, and emergency department providers.
The system works when the NCCCN Call Center connects sickle cell patients with the appropriate primary care for SCD. The Call Center provides a single telephone number that the emergency department staff can use to arrange referrals for both Medicaid and non-Medicaid sickle cell patients.
At this point, managers can review their treatment history, arrange follow-up care as necessary, and work closely with patients to help them reach their health goals. Non-Medicaid patients are referred via secure messaging to a state Sickle Cell Educator.
“Call Center staff reaches out to more than 10,000 patients a month,” reports Call Center Manager Deborah Murray, RN. “This is particularly helpful with sickle cell since patients can sometimes fall through the cracks and not get the care they need to stay out of emergency departments and hospitals.”