ED Innovation Team

The ED Innovation Team is a collaborative focused on reducing inappropriate ED usage. This team is represented by a broad provider community including:

  • Ed Providers
  • Primary care physicians
  • MEDIC
  • Mobile Crisis
  • County Provided Services
  • CMC Psychiatry
  • CHS ED leadership
  • Behavioral health providers (86% of our high ED utilizers have an identified BH care component)
  • Novant ED leadership
  • CCPGM Staff
  • Pharmacists

ED Innovation Team On-Going Planning and Work

The ED Innovation Team (EDIT) is a community-based collaborative focused on ensuring appropriate ED usage and access to care. This team is represented by a broad provider community including physicians, behavioral health and substance use specialists, Novant Health and Carolinas HealthCare System emergency department care managers, law enforcement, CCPGM staff and other partners, such as health departments, housing and the justice system.

  • Customized Care Plans created with patients, families, ED providers, PCPs and specialists target the needs of each patient to reduce inappropriate ED usage and ensure continuity of care.
  • CCNC’s Provider Portal enables real-time tracking (24-48 hours) of ED visits across systems.

  • Novant Health, Carolinas HealthCare System and CCPGM care managers work closely to ensure linkage to resources.

Behavioral Health Integration Program

An integration of behavioral health and primary care services is necessary to break the “Silo” system of care that too often fails to meet the needs of those patients who have both behavioral and physical conditions. CCPGM is committed to advancing efforts to create a health system that recognizes the complex interaction of mind and body.

CCPGM supports primary care practices becoming the medical home both for enrollees with mild to moderate behavioral health issues being served in the primary care system, and those with severe and persistent mental illness being served in our specialty behavioral health system.
Current Behavioral Health Integration Initiative projects include:
-Chronic Pain Initiative
-Depression Toolkit for Primary Care
-Integrated Care Training Program

Behavioral Health Integration

Over the past seven years, CCPGM has partnered with Managed Care Organizations-Local Management Entities (MCO-LMEs) in our three counties to facilitate behavioral health integration. These currently include Cardinal Innovations in Mecklenburg and Union counties and Sandhills Center in Anson County.

We have expanded our behavioral health transitional care program, as patients are discharged from the inpatient behavioral health episodes of care. This work has been instrumental in moving CCPGM’s high-than-the-state average hospital readmission rate to a lower-than-average rate.

With the MCO transition to Cardinal Innovations in 2014, we expanded this evidence-based transitional care process and added Behavioral health nurses and social workers to a program known as PROACT (Preventable Readmissions Options and Care Transitions).

Chronic Pain and Opioid

The Chronic Pain Initiative is designed to improve the medical care received by chronic pain patients, and in the process, to reduce the misuse, abuse, potential for diversion and overdose from opioid medication.

  • Give resources to providers about substance abuse facilities and alternative pain therapies
  • Provide handouts from CDC about Guidelines for Prescribing Opioids
  • Patient instruction sheets for how to discard old or unused medicine
  • Chronic Pain Initiative Tool Kit created for Primary Care Providers and Emergency Department Providers
  • Pain Management Agreement for providers and patients

Key Program Components:

Clinical:

  • Primary Care Physician Toolkit
  • Emergency Department Toolkit
  • Care Management Toolkit
  • Network CPI Champion

Community Focus:

  • Take only your own medications
  • Keep medications in a safe place
  • Education on dangers of opioids

Goals: 

  • Reduce opioid-related overdoses
  • Manage substance abuse issues (opioids)
  • Optimize treatment of chronic pain

Fostering Health NC

  • Fostering Health NC is a multi-faceted approach to developing and strengthening medical homes for children in foster care. The North Carolina Pediatric Society, the state’s chapter of the American Academy of Pediatrics, introduced this initiative.
  • It is designed to help the 11,000 children in foster homes statewide receive better care for improved health outcomes. CCPGM’s staff will identify foster children in Anson, Mecklenburg, and Union counties to improve their access to health care. Each child will be assessed to identify those in need of case management.