transitional care timeline outcomes* case study acknowledgements


A Collaborative Community Approach for The High Risk, High Need Patient Community Care of Wake and Johnston Counties and Wake EMS

CCWJC: COMMUNITY CARE OF WAKE AND JOHNSTON COUNTIES CCWJC is the Community Care network for Wake and Johnston Counties with 170 Primary Care Practices in the network. CCWJC serves approximately 123,000 recipients including NC Health Choice, Carolina Access Medicaid, Carolina Access Medicaid/Medicare (duals) as well as other select Medicare and commercially insured patients and, through our sister organization, uninsured patients. Emergency Department visits

Prescription drug costs

Increase Quality Decrease Costs

The program aims to address high rates of hospital readmissions among patients with primary diagnosis of CHF by: 1. determining specific interventions that will effectively address current gaps in care. 2. maximizing efficiency and effectiveness using resources and strengths of both programs. Primary objectives:  Improve patient outcomes and patient experience  Reduce ED visits/hospitalizations  Reduce total costs

Hospitalization rates

30-day hospital readmissions rates

TRANSITIONAL CARE Core components of CCWJC Transitional Care:      


Redirect: Not all patients need an emergency department evaluation – experienced paramedics can help with destination decisions  Leaders in Alternative Destination: assess and divert patients from local Emergency Departments, according to medical screening criteria.  It is estimated, 576 additional chest pain beds were made available in the ED following transfer of 477 screened MH/SA patients to an alternative specialty facility (FY 2014-15). Reduce: Proactive, planned well-person checks for patients with Diabetes, CHF, COPD, and other chronic illnesses  informal counseling  health education  referrals for follow-up services  medication administration  other home-based services


 Average time to coordinated visit: 6.89 days after discharge  Number of APP visits: 79 Total APP visits (approximately 3 per patient)  100% of patients surveyed (n=11) reported satisfaction with care Utilization:

 For these 21 patients, ED costs were maintained (approximately 4% decrease) 3 months prior to 3 months after entry date  3 months after program entry, hospitalization cost to Medicaid were reduced by 90% in comparison to the 3 months prior to entry.

The initiative began with a small patient cohort at 1 hospital (WakeMedRaleigh) in Fall 2014. As of March 2016, the program has enrolled 22 patients and phased in all Wake County hospitals.


CASE STUDY  Transitional Care support reduced ED utilization by 30% and readmission rates by 53% for the 12 month time period before and after engagement in the Initiative  Increased average number of days between admissions from 39 pre-entry to 85 post-entry.

46 year old patient with CHF; EF of 10-15% admitted > 200 days during 2014-2015, with rapid readmission cycle. Enrolled in pilot program in April, 2015  Healthcare expenditure 3 months prior to intervention: $103,409  Healthcare expenditure 3 months after intervention: $557 

Total Medicaid Costs:  Data taken in 3 month segments for the 12 month pre and the post period  Does not account for all costs for patients dually enrolled in both Medicaid and Medicare

 Actual potentially preventable readmission rate between 2012-2015 for patients enrolled in CCWJC is 40% of expected readmission rate

Respond: Critical medical emergencies occur and require an experienced paramedic to mitigate

Process:  Average time to initial APP visit: 2 days after discharge

The scope of the program includes those patients actively engaged in Care Management with high ED/hospital utilization related to CHF, and complex psychosocial issues.

 Achieved NCQA Complex Care Management accreditation in 2015

16 Advanced Practice Paramedics (APPs) with over 200 hours of didactic and clinical training. APPs aim to deliver mobile, timely, responsive, afterhours assessment and service.


*One patient outlier excluded from all proceeding figures


Face-to-face contact (hospital visit and home visit) Comprehensive medication management with med rec Patient/caregiver self-management education, “red flags” Timely outpatient follow-up with informed medical home Link back to specialist, home health, BH system Connect with community resources and address social needs



 Embedded hospital Care Manager (CM) notifies APP 24 hours prior to discharge  Home visit conducted by APP within 1-2 days; may provide additional visits until warm hand-off to CCWJC CM  APP interventions include: general assessment, med reconciliation, red flag education, and assessment of barriers to care  Home visit(s) by CCWJC CM in coordination with APPs within 7 days of discharge  Patient Satisfaction surveys conducted by CCWJC CM for Wake EMS  CCWJC CM completes 30-day transition period

MEASURES Process Measures: • Time to initial APP visit • Time to coordinated/joint visit • Number of APP visits • Patient satisfaction Clinical Elements include: link with Cardiologist, link with PCP, ability to teach back red flag symptoms associated with CHF, and med compliance. Outcome Measures: • Number of hospitalizations • Number of ED visits • Total Medicaid costs per patient

APPs completed first home visit within 24 hours of discharge  Discovered medication gap and worked with CCWJC care manager to resolve  Provided immediate red flag education and monitoring Joint home visit completed by APP/CCWJC CM within 4 days  Pt. linked with PCP and pain specialist  Linked with a local Community Pharmacy Enhanced Services Network (CPESN) pharmacy for med synchronization and delivery services  No subsequent inpatient admissions for remainder of time in pilot program (through September 2015)

NEXT STEPS  Expand to more patients and consider other diagnoses  Explore financial sustainability  Enhance activities to further address social determinants of health

ACKNOWLEDGEMENTS  12 months after program entry, emergency department costs to Medicaid were reduced by 60% in comparison to the 12 months prior to entry.  12 months after program entry, inpatient costs to Medicaid were reduced by 45% in comparison to the 12 months prior to entry.  50% of patients enrolled had no hospitalizations one year following entry into the program. Community Care of Wake and Johnston Counties 2500 Blue Ridge Rd, Suite 330 Raleigh, NC 27607

Jamie Philyaw, MSW, CCM Benji Currie, NREMT-P Michael Bachman, EMT-P, MHS Elizabeth Cuervo Tilson, MD, MPH Ben MacDonald, RN Atha Gurganus, MPH Sarah DeLozier, BA


transitional care timeline outcomes* case study acknowledgements

A Collaborative Community Approach for The High Risk, High Need Patient Community Care of Wake and Johnston Counties and Wake EMS CCWJC: COMMUNITY CA...

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