Ron Gaskins, Associate Director of the Northwest Community Care Network, is completing a Doctorate of Health Administration from Central Michigan University.

Within healthcare reform there has been significant discussion regarding hospital readmissions. This has become a key indicator for not only the health of patients but the quality of care at transitions.

The Centers for Medicare & Medicaid Services has selected 47 communities throughout the United States that are focused on improving care for Medicare fee-for-service beneficiaries at points of transitions. Northwest Community Care Network was the first in the Carolinas to be awarded the Community-based Care Transitions Program (CCTP) funding and is acting as the lead community-based organization (CBO).

Northwest Community Care Network is a not-for-profit organization, based in Winston Salem, that provides care management services to the Medicaid populations in Davidson, Forsyth, Stokes, Surry, Wilkes, Davie, and Yadkin counties. The Network’s mission is to provide the highest quality care in the lowest cost environment.

Through CCTP, the network is a coalition built upon collaborative partnerships encompassing eight hospitals, two home health agencies, three senior services agencies, and Right-at-Home, an in-home aide provider. The program will serve targeted Medicare beneficiaries in three northwest North Carolina counties (Surry, Forsyth, and Davidson) which blend urban and rural communities. The program will enroll Medicare fee-for-service beneficiaries who are discharged from the hospital to the home. In all eight of the participating hospitals, we are targeting the four admitting diagnoses of heart failure, pneumonia, heart attack, and COPD, as these diagnoses are a predictor of frequent readmissions.

For program design the coalition chose the “Hospital to Home” model at Forsyth Medical Center as the foundation to reduce 30-day readmissions for the four diagnosies. “Hospital to Home” is a social worker model that consists of a patient navigator who engages the Medicare fee-for-service beneficiary at the hospital and transitions them into the home post-discharge.

At the home the patient navigator will conduct a reconciliation of medications targeting discrepancies while performing a full needs assessment for community supports. This assessment will encompass screenings for depression and palliative care, among others, and ensure appropriate follow-up with community-based services. The patient navigator will also act as an advocate around primary care appointments, help educate on chronic disease self management, and keep the beneficiary in his or her case load for six months.

If the beneficiary shows demonstrated need, the patient navigator will also engage Right at Home for short-term patient assistance with basic activities such as cooking, grocery shopping, light housekeeping, and laundry services. The patient navigator will also refer the beneficiary to the local senior services coordinator who will provide support for long-term community-based services, all at no cost to the beneficiary and paid for by CCTP funding.

To facilitate communication among the care team, a web-based application called Case Management Information System (CMIS) will be utilized for patient documentation. The patient navigator, Right at Home, senior service coordinator, and home health worker will use this tool for patient coordination. CMIS will allow all members of the care team to share information with one another through secure messaging so that a common care plan can be developed in the hope of improving patient outcomes.

The goal of the Northwest Triad Care Transitions Program is to improve patient quality by reducing the aggregate 30-day all cause readmissions across the eight hospitals by 20 percent over two years. CMS may extend funding annually for three years based on achieving the reduction in avoidable readmission.

The program started enrolling patients October 8 with future projections of enrolling 1,300 patients annually over the two-year period.