0

Community Care of North Carolina reduces ER admissions and Saves millions of Dollars Statewide

Rationale / Objectives

Recurrent hospitalization is a substantial and huge financial burden in the United States. In North Carolina the aged, blind and disabled group represents 30% of the N.C. Medicaid population. However, it generates about 70% of the program's health care costs because of the patients' complex chronic conditions and related high hospitalization and readmission rates. Community Care of North Carolina (CCNC) wanted to integrate Medicaid's aged, blind and disabled recipients into its medical home model. The goal was to help these patients transition from the hospital back into their communities and reduce hospital readmissions.1

Project/Program Description & Major Achievements

CCNC initiated a population based transitional care program to help those patients transition from the hospital back into their communities. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. 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. 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. In 2014, the system prevented one readmission for every six patients who receive this transitional care support.1 2 3

 

Lessons Learned

  • Target the intervention to the people with multiple chronic conditions who are most likely to benefit and move away from disease-specific management and narrow interventions Close participation in discharge planning is imperative through access to real-time hospital data
  • Hospital-embedded Care Manager/Pharmacist teams establish relationships with patients and begin medication reconciliation as early as possible. Bedside visits and participation in discharge planning by CCNC Behavioral Health Coordinators has improved behavioral linkage and follow-up upon discharge.
  • Home visits are extremely valuable and the best setting for medication reconciliation. Collaboration of Network Pharmacists, Behavioral Health Coordinators and Palliative Care Coordinators as part of a team greatly improves the management of transitions.1 2

Further Description

The Community Care of North Carolina (CCNC) transitional care initiative created care management teams. These teams are coordinated by nurse care managers, health educators, social workers, behavioral health specialists and clinical pharmacists. The transitional care is a comprehensive plan of care based on multiple elements which includes: Electronic links with almost all the hospitals in the state, allowing receipt of timely information about Medicaid patients in the hospital and ED Patients at high-risk for a failed transition receive a home visit within 3 days of discharge, beginning with “medication reconciliation.” by a nurse care manager, pharmacist and primary care physician. Care Managers ensure patients have a follow-up appointment with their medical home, soon after discharge. The Care Managers provide timely information to the primary care doctor/medical home about hospitalizations, medications prescribed, social and environmental concerns, and other agencies providing services to our Medicaid patients The goal of these partnerships was to coordinate care in an effort to better meet patients’ needs without duplication of services and ensure providing a high quality, cost-effective health care. [1,2]

Major Achievements

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. 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. Cost savings, ranging from almost $ 190.91 per member per month (PMPM) in the first year to $ 63.74 PMPM in the last study year, with higher savings observed among patients with multiple chronic conditions. The amounts to a total savings of $389 million in fiscal year 2014 alone. [1,3]

Metric Result Detail
 Readmission rate among Medicaid patients enrolled in CCNC Declined 10.3 % Between 2008-2014
Readmission rate among North Carolina Medicaid patients  enrolled  in CCNC 471 admissions for every 1,000 with multiple chronic conditions  
Readmission rate among North Carolina Medicaid patients  not  enrolled  in CCNC 932 admissions for every 1,000 with multiple chronic conditions  
Cost savings $389 million Fiscal year 2014
Cost savings per member per month $190.91 $63.74 In first study year In last study year