Best Practices: Customizing transitional care for N.C. Medicaid patients

Healthcare organizations are increasingly trying to crunch data to find patients who are at risk of being hospitalized and returning to the hospital soon after going home. But finding them doesn't mean they'll all respond to the same kinds of interventions.

A not-for-profit group that works closely with the North Carolina Medicaid agency has developed a data-driven transitional-care program intended to connect the right patients with the resources that are most likely to work.

The physician-led Community Care of North Carolina, which coordinates care for 1.4 million Medicaid beneficiaries, created an algorithm two years ago based on transitional care delivered to more than 100,000 patients. The process produces an “impactability score.”

“Traditional models look at risk,” said Dr. Tom Wroth, CEO and chief medical officer of North Carolina Community Care Networks, the Medicaid arm of CCNC. The impactability score, Wroth said, “predicts prospectively which patients are going to benefit from which transitional-care interventions.”

With this approach, CCNC has significantly reduced hospitalizations for some of the state's sickest patients. In March it was selected as the winner of the inaugural Hearst Health Prize, a $100,000 award recognizing outstanding achievement in managing or improving health.

Since the program began in 2008, hospital admission rates for Medicaid recipients with multiple chronic medical conditions have declined by 10%, according to the organization. Readmissions for the same group have dropped by 16%.

For example, a 6-year-old boy had more than 30 emergency department and hospital visits in a year because of seizures. One episode resulted in a 16-day hospital stay. Under the transitional-care program, a care manager helped the boy's mother find a new pediatrician and get a referral to a neurologist who initiated a new treatment plan. A few weeks later, the boy was stabilized with the help of medication and went seizure-free for almost a year.

The success of the model relies on a broad menu of interventions. The individual components of the program—which supports about 2,600 Medicaid patients each month—aren't revolutionary. They include coordinating communications and linking patients back to primary-care providers.

One key element is rigorous medication management. A team that might include a case manager, pharmacist and primary-care physician gathers medication lists from all of the providers a patient has seen. The team then generates a consolidated, cost-effective medication regimen.

The pharmacist is a crucial part of the transitional-care team. CCNC has empowered about 300 pharmacies to take an active role in patients' care. The pharmacies have access to the organization's informatics platform. Since patients tend to visit the pharmacy more often than they see their primary-care physician, it offers opportunities for additional touch points and follow-up.

The role of the care manager—typically either a registered nurse or a social worker—is also critical. CCNC trains care managers to be the “quarterback” of the care team and use motivational interviewing and other techniques to strengthen the likelihood of changing behavior, Wroth said.

Local hires also make a difference. “They have the same accent, they know the patients,” said Paul Mahoney, CCNC's vice president for communications. While other companies use out-of-state call centers to help direct patients to services, “our folks know what they have here. They know the local players and where the small support operations are.”

CCNC staff are also placed at hospitals that discharge large numbers of Medicaid patients to educate patients and family members on “red flags,” indicating when a doctor or care manager should be called. Care managers follow up soon after discharge.

The transitional period typically lasts about 30 days. During that time, the patient might be referred to other programs for ongoing support. “We're defragmenting the healthcare system for patients,” Wroth said.

The model, meanwhile, could be upended by the state's plans to move to a Medicaid managed-care model in which benefits would be administered by private health plans and provider-led groups.

While state leaders pursue the necessary federal waiver, CCNC leaders intend to streamline operations so they can continue working as partners with whatever entities assume responsibility for the state's Medicaid population. The transitional-care approach, Mahoney said, “makes us valuable to any risk-bearing entity seeking to operate under the new managed-care system.”