1. Anthony, Maureen PhD, RN

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It recently came to my attention that Community Care of North Carolina in Raleigh was the winner of the first Hearst Health Prize, in recognition of outstanding achievement in managing or improving health. I caught up with C. Annette DuBard, M.D., MPH, Chief Health Information Officer, and Senior Vice President Population Health Analytics, CCNC, Inc., to find out more about the award and their outstanding work.

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Congratulations on winning the Hearst Health Prize! What can you tell us about the award?

Community Care of North Carolina (CCNC) is honored to be the first recipient of this prestigious award. The Hearst Health Prize, in partnership with the Jefferson College of Population Health, is a newly created program in which a $100,000 cash prize is awarded in recognition of an organization's or individual's outstanding achievement in managing or improving population health.


How does your organization impact population health?

CCNC takes a population management approach to improving healthcare and containing costs for North Carolina's most vulnerable populations. As the physician-led nonprofit that coordinates care for the state's 1.4 million Medicaid beneficiaries, CCNC implements a statewide Primary Care Case Management program, in which primary care providers are responsible for approving and monitoring the care of enrolled Medicaid beneficiaries. CCNC does this in a collaborative approach with local physicians, hospitals, health departments, and departments of social services.


What were the best practices utilized by your organization to improve quality of care that led to this recognition?

In 2008, CCNC began tracking the problem of recurrent hospitalizations, which represent a substantial and often preventable human and financial burden. There was a need to improve quality of care and control spending for older adults and disabled individuals receiving Medicaid who commonly experience multiple health conditions. CCNC recognized coordination and continuity of care at times of transition are critical to achieving better health outcomes at lower costs. North Carolina initiated a statewide rollout of a population-based transitional care initiative in the fall of 2008 for Medicaid recipients enrolled in CCNC. The core tenets of CCNC's transitional care program are: comprehensive medication management, face-to-face self-management education for patients and families, and timely outpatient follow-up with a medical home that has been fully informed about the hospitalization and any clinical or social issues that complicate the patient's care. Specific interventions and best practices include:


* Access to real-time hospital data. This allows us to know who is in the hospital, to intervene in a timely fashion.


* Close participation in discharge planning to establish relationships with patients and caregivers as early as possible.


* Bedside visits and participation in discharge planning by CCNC Behavioral Health Coordinators.


* "Connecting the dots" back to the patient's primary care medical home and assuring seamless communication across settings of care.


* Home visits are extremely valuable and the best setting for engagement with caregivers, patient-centered care plan development, medication reconciliation/medication management, and education.


* Partnerships with home healthcare agencies for better coordination of care through established workflows to include a "warm hand-off" approach when home healthcare is ready to discharge.


* Collaboration among network pharmacists, behavioral health coordinators, and palliative care coordinators as part of a team greatly improves the management of transitions.



By using CCNC Transitional Care Impactability Scores(TM), CCNC is able to make decisions about which patients to prioritize for transitional care management, as well as who should receive specific components of that intervention. Care team members strive to engage patients at the bedside to establish a relationship and begin discharge planning to assess for needs, barriers, personal goals, and so on to ensure a smooth transition from hospital to home.


What have you learned from this journey?

Over the past 3 years, CCNC has conducted a series of rigorous evaluations to further refine how to identify patients who require intervention, which interventions work best for specific populations, and the optimal time to intervene. For example, a study published in the journal Population Health Management found home visits reduced odds of hospital readmissions by half compared to less-intensive forms of transitional care support, but certain patients are much more likely to benefit than others. Among highest risk patients, the incremental benefit of the home visit amounts to 37 additional admissions averted over 6 months for every 100 patients, compared to less-intensive forms of transitional care support.


Similarly, in study recently published by the Annals of Family Medicine, CCNC investigators described that a majority of patients discharged from the hospital do not benefit meaningfully from early outpatient follow-up, but securing early follow-up appointments for certain higher risk patients will decrease readmission rates by up to 20%. CCNC researchers also described a risk segmentation methodology for discerning which patients are most likely to benefit from early outpatient follow-up.


CCNC has now operationalized what we learned about what works for transitional care through the creation of the "Transitional Care Impactability Score(TM)." This score encapsulates findings from real-world controlled evaluations about expected savings to be achieved from transitional care management, and allows CCNC to make more judicious decisions about which patients to prioritize for transitional care management, as well as who should receive specific components of that intervention.


Congratulations to all at CCNC for their remarkable work in population health and improving transitional care for vulnerable patients!


Best wishes,

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