CCPGM’s Transitional Care Team connects with priority hospital patients, while developing ways to reduce emergency department usage. 

By Christopher Sardelli

Michelle Levine recently received some unanticipated, but very welcome, feedback regarding the Transitional Care team.

As manager of Community Care Partners of Greater Mecklenburg’s TC team, Levine’s main goals during the last two years have been figuring out how to connect with priority patients recently admitted to the hospital, while also testing ways to reduce their emergency department utilization.

Though she’s familiar with using quantitative data to evaluate the team’s effectiveness, it can be difficult to measure the actual human impact. That changed when Levine received a phone call from a male patient last month.

“He started off saying ‘I need to talk to you about one of your nurses,’ which initially caused me to worry, but instead he went on and on and on about how amazing (CCPGM Primary Care Manager) Julia Mullins was and how when she came out to his home she really listened,” Levine said. “He told me ‘I’ve never felt like people ever really listened to me and felt that they were just talking at me. (Julia) sat and let me talk and say my concerns. She was absolutely amazing and because of that great experience I want you guys to manage my care.’”

The patient previously expressed no interest in engaging with the TC team, but had a change of heart, Levine said.

“That was refreshing to hear that praise,” she said.

Based on recent statistics, ED utilization amongst priority patients has decreased, though Levine said it’s hard to attribute that improvement to just her team.

“There are so many factors why that could be, so we can’t say specifically that our TC team is the sole reason,” she said. “But what I do know is our goal is to see large numbers of patients. We’re responsible for 75 percent of patients in the hospital that are priority and we’ve been exceeding that goal. We’re now reaching about 90 percent. A lot of work has been done to achieve this.”

The TC team, made up of four nurses, two patient coordinators and one data coordinator, is generally the first contact CCPGM has with patients who have been admitted to the hospital. They work with CAII patients who have a TC priority or a CCNC priority score of 200 or above, a number based on their hospital utilization.

“For that reason, we’ve identified them as someone with whom we can intervene and lower the cost of Medicaid billing,” Levine said. “Our role is we receive a list of priority patients from the hospital and we’re responsible for seeing all the patients in the hospital and explaining the program to see if they want us to manage their care.”

She said the first 30 days is the time when patients have the highest likelihood of being readmitted.

“This can often can be because of medical issues, if there is a duplication of medications, if they didn’t get all their medications filled or didn’t understand how to take them. So, because of all those reasons, we like to do face-to-face visits afterward,” she said. “If we can’t do a home visit, we do a practice visit and go with them. Sometimes they don’t want us in the home so we do a community visit and meet them at a shelter or library. We go where they want us because the best thing is having that face-to-face visit.”

Levine said Transitional Care is a hot topic in the healthcare world.

“If we can give the patient all the things they need in the first 30 days to 60 days post ED, to give wraparound services, then that’s our goal,” she said.

The team’s effectiveness recently caught the attention of Carolinas HealthCare System, which bestowed the team with a Silver Touchstone Award for their ability to use Motivational Interviewing techniques to improve Transitional Care. Levine and her team will present their statistics during the CHS Quality and Patient Experience Sharing Day on Aug. 9.

“We’ve done really well! I think that’s what we’re most proud of. The team has really done a lot of team building, is focused on Motivational Interviewing and on getting patients to engage,” she said. “Getting the patient to know us and how we can care for them helps them to trust us. Once they trust us, patients will tell the care managers things about their condition they haven’t told anyone else. That’s when they begin engaging with the care managers.”

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