Community Care of North Carolina Developing State-level Capacity to Support Superutilizers Policy Academy Meeting L. Allen Dobson, Jr., MD President and CEO
Cherokee Graham Swain Clay Macon Jackson Haywood Madison Buncombe Henderson McDowell Rutherford Polk Burke Cleveland Watauga Caldwell Alexander Catawba Lincoln Gaston Ashe Wilkes Alleghany Surry Yadkin Iredell Mecklenburg Union Stanly Cabarrus Rowan Davie Stokes Forsyth Davidson Anson Rockingham Guilford Randolph Montgomery Richmond Caswell Chatham Orange Person Lee Moore Hoke Scotland Robeson Cumberland Harnett Wake Franklin Warren Johnston Sampson Bladen Columbus Brunswick Pender Duplin Wayne Wilson Nash Halifax Northhampton Edgecombe Pitt Greene Lenoir Jones Onslow Craven Pamlico Beaufort Hyde Martin Bertie Hertford Gates Washington Tyrrell Dare Alamance Durham Granville Hanover Chowan a r
Resources for local management Primary care physicians State provides variable (ABD/non-ABD) PMPM to support care management Regional Networks State provides variable PMPM for network director, clinical director, behavioral coordinator, care managers Central office PMPM for data backbone, quality improvement, leadership, strategy and other global needs Partnerships with local health departments, hospitals, free clinics, etc. 3
Five core elements for managing super-utilizers 1. Framework for expansion and scalability 2. Data real-time feeds and insight into actionable patients, find patients who bounce around system 3. Community framework support services beyond docs and hospitals 4. Care management more intensive manpower as co-enzyme 5. Leadership and accountability from local physicians 4
Transitional Care Program Core components of CCNC Transitional Care Face-to-face contact Comprehensive medication management Patient/caregiver self-management education, red flags Timely outpatient follow-up with informed medical home Collaboration with partners/ resources to maximize reach and avoid duplication of services. Local flexibility, many local innovations Automatic notification of hospital admissions via Informatics Center started 12/10 Now get ADT data three times daily from 57 hospitals (2/3 of discharges) 5
Geographical Reach of CCNC Transitional Care Interventions Each dot represents the home address of a client who received transitional care services between July 2011 and June 2012. As of December 2012, we were providing transitional care management for approximately 4,500 patients per month. 6
Transitional Care Study 21,375 Medicaid recipients with complex chronic conditions and a hospital discharge July 2010 through June 2011 13,476 patients received transitional care assessment or intervention Program to scale: 120 different hospitals 1,325 primary care medical homes 99 of 100 NC counties.
Transitional Care Results 20% reduction in readmissions for patients in transitional care program. 12-month readmission rates consistently lower for participants within each level of clinical severity. For every six interventions, one hospital readmission avoided strong ROI
Transitional Care Scenario T, a 14-year-old female with cerebral palsy/asthma who that requires extensive care from family Recent NY transplant unfamiliar with local resources for care multiple inpatient admittances; Initially reluctant to work with care manager; won over by consistent willingness to help family overcome barriers to care. CM tapped personal contacts to find retired contractor who provides handicapped ramps and railings for free, getting patient exercise, fresh air 9
Transitional Care Scenario Care manager works closely with PCP, e.g., expedited replacement for suction machine family brought from NY CM connected child to CAP/C program, home health aid, new wheelchair/scooter CM assisting patient s twin sister locate a CPR class so she can more confidently help grandmother with her sister s care. Engaged patient and family around an attractive goal: get T well enough to go fishing this summer. 10
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