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.
Annette DuBard, M.D., M.P.H., (right) discusses a patient's care instructions with a medical assistant.
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.
- Community Care of North Carolina's (CCNC's) transitional care initiative supports its Medicaid patients and prevents one readmission in the coming year for every six patients in the program.
- CCNC now provides transitional care to about 2,600 Medicaid recipients every month, with 1,800 participating primary care practices that care for 1.3 million Medicaid beneficiaries.
- Between 2008 and 2014, CCNC 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.
CCNC's system of 14 networks crisscrosses North Carolina, providing support to primary care physicians and their Medicaid patients with wrap-around services provided by more than 800 care managers and through hospitals, social service agencies and other community providers.
CCNC now provides transitional care to about 2,600 Medicaid recipients every month who are enrolled in its medical home program, with 1,800 participating primary care practices that together care for 1.3 million Medicaid beneficiaries.
"It's a large-scale program," DuBard said. "But our emphasis on the face-to-face interaction with patients and their community and linking it back to that longitudinal primary care relationship is a somewhat unique focus of our particular approach."
Transitional Care at CCNC
During the transitional care initiative's launch, care management teams were created and embedded at the local level in each region the system serves. These teams are "quarterbacked" by nurse care managers, but they also include health educators, social workers, behavioral health specialists and clinical pharmacists who can provide this wrap-around care coordination support and become a shared resource to participating primary care physicians.
During home visits, transitional care managers use hospital discharge information to guide a discussion with the patient and family about their care plan, including a review and comparison of medications on the discharge instructions with those on medication lists from the primary care health professional's patient record and with all pills in the patient's purse and/or medicine cabinet to identify confusion or duplicative prescriptions or other issues that need to be resolved.
"We pay a lot of attention to medication review and getting the medications right," DuBard said. "Because this frequently is a source of confusion and problems and has potential for adverse events."
Care managers also educate patients and caregivers about warning signs that the patient might require intervention by the medical team. In addition, they work with patients on scheduling follow-up appointments with their primary care health professionals and communicate back to the physician any outstanding issues or major changes that need their attention.
"Often, our care managers will accompany the patient to the follow-up visit with their primary care provider to make sure that transition is smooth," she said.
DuBard said CCNC's transitional care model has proved to be extremely successful. "There is a lot of evidence out there backing its success in reducing readmissions and total health care costs during the following 12 months, among other things," she added.
Crunching the Numbers
CCNC's central office in Raleigh, where DuBard works, provides the statewide transitional care program its informatics infrastructure, which focuses on data, analytics and information systems. That infrastructure is a critical component of providing this care efficiently and cost-effectively, according to DuBard.
"We bring in data from a number of sources and use it to risk-stratify and identify patients most likely to benefit from interventions," she said. "We message that information out to our care teams to get the information into the right hands at the right time to best impact the care of those patients at the time they need it."
For the most part, CCNC's data show the patients who are being readmitted are those who have multiple chronic conditions.
"One of our learnings during (the program) has been to move away from disease-specific management and narrow interventions like specific interventions for diabetes, asthma and heart failure and recognize that most patients at highest risk for admission and driving health care costs are people with multiple chronic conditions in multiple organ systems with complex care needs," DuBard said.
CCNC is able to use a robust set of medical claims, pharmacy records and other clinical data to identify a patient's risk for readmission.
"So we are fairly precise in being able to identify folks with a greater than 10 percent 30-day readmission risk," DuBard explained. "These people are flagged as likely to benefit from CCNC's transitional care management interventions. For patients with a greater than 30 percent readmission risk, we flag them as highest priority for a very intensive intervention including a home visit and earlier outpatient follow-up with the primary care provider."
Care managers get real-time notification of hospitalization of Medicaid patients from most of the hospitals in the state and typically follow up with the patient and family within three days after hospital discharge.
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."
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