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    Care Coordination Domain – Achieving a New Standard of Care

    CCHC Ranks #1 in the Country in Quality

    CCHC is proud of the transformational work taking place in our practices with a focus on delivering excellent care to the communities we serve. CCHC, as part of an MSSP ACO, has chosen to be accountable to Medicare for the quality it provides to the program’s beneficiaries.  To measure quality performance, Medicare uses four domains.  Last month our article focused on the quality domain, patient experience, and this month we are focusing on the Care Coordination and Patient Safety domain.

    This domain includes measures related to how frequently our patients require readmission to the hospital as well as measures tied to programs and tasks that research has shown result in better care and fewer hospitalizations.

    To help excel in this quality domain our organization chose to develop dedicated teams of nurses to assist its physicians and other clinicians in providing more proactive care to help better explain medication regimens, review instructions, assist in communication between providers, and much more.

    CCHC Care Managers Become a Bridge

    Coastal Carolina Health Care (CCHC) has taken focused, personalized, and detailed patient care to the next level with their Care Management Program.  This program consists of a team of 7 dedicated registered nurses providing support to over 2,000 of our 13,000 patients covered by Medicare.

    Many of those served by the program have been in and out of the hospital due to various and ongoing medical issues. Some may not have family in the area to help with trips to the doctor or at-home care. A few may not even have a friend or acquaintance to help them navigate the complex medical system and recommended treatments.

    Thankfully, the Care Managers at CCHC form a bridge between these patients and their team of nurses, pharmacists, advance practice providers, and physicians by giving support, advice, medication reminders, phone check-ups, home visits, and sometimes just a sympathetic ear.

    According to the Agency for Healthcare Research and Quality (AHRQ), 90% of hospital readmissions are unplanned. Such high numbers are often attributed to poor care coordination and continuity: Fewer than half of re-hospitalized patients actually see a physician prior to readmission, and studies also show that nearly 20% of Medicare discharges are followed by an adverse event within 30 days, usually related to medication mismanagement. The good news is that CCHC’s Care Management program, combined with the hard work and dedication of CCHC team, has resulted in our patients, covered by Medicare, needing fewer readmissions to the hospital.

    The following is a more detailed description of the services offered by CCHC’s care managers:

    Personalized help from a registered nurse working to create a care plan based on the patient’s needs and goals. A Care Manager can work to ensure a patient understands and can perform rehabilitation exercises at home. Or, she can work with a diabetic patient to create an easy-to-follow diet to help regulate blood sugar.

    Care coordinated between your doctor or advance practice provider, pharmacy, specialists, testing centers, hospitals, and other medical services. If a patient has trouble taking the correct medications at the correct times each day, a Care Manager can work with any pharmacy to create “punch packs:” multi-dose packets which contain all the medications taken by someone at a given time of day (breakfast, lunch, dinner, and bedtime). She also can help with setting up appointments with specialists, therapists, and lab centers. One of a Care Manager’s most important duties may be to attend doctor appointments with her patient to take notes concerning treatment plans, to be an advocate for his or her best interests, and to help make sure the care team is aware of any changes in the patient’s health or medications.

    Phone check-ins between visits to keep patients on track. Not only will a Care Manager follow up with a patient within 48 hours of a hospital admission, but she will also make phone calls between doctor visits to make sure a patient is taking medication properly, following instructions given by the care team, and generally doing well. After visits to the clinic, a Care Manager will check in with the patient to monitor his or her progress and answer any follow up questions.

    Emergency access to a health care professional, 24/7. Patients—and their loved ones—can rest easy knowing that a Care Manager is just a phone call away at any moment. If a health issue arises suddenly, she can advise on next steps or work her “magic” to set up an appointment with the patient’s primary care doctor as soon as possible. If necessary, a Care Manager will make a home visit to ensure a patient’s needs are met. All CCHC patients have access to a registered nurse or an Advance Practice Provider when our offices are closed. Patients can call 252-636-NURS (6877) and speak to a clinical professional about symptoms, medication questions, or for reassurance.

    Expert help with setting and meeting your health goals. Working closely with a Care Manager can ensure a patient meets and even exceeds his or her health goals. She can make sure the diabetic patient is checking blood sugar on a regular basis and eating the proper diet. She can double check to confirm a patient is taking a daily walk like the doctor ordered. Did the patient take the full round of antibiotics prescribed by his physician? She can explain why doing so is important and hold the patient accountable.

    For detailed quality results, in all quality domains, visit www.ccqchealthcare.com

    Coastal Carolina Health Care (CCHC) offers medical care services with offices located in New Bern, Pamlico County, and Morehead City. CCHC is physician owned and operated and always welcomes new patients. Call our Patient Information Line today at (252) 633-4111 or visit www.cchchealthcare.com.

    (Sources: U.S. Centers for Medicare & Medicaid Services; American Hospital Association; Patient Safety & Quality Healthcare; Healthcare Financial Management Association; Agency for Healthcare Research and Quality; Stratis Health; Partnership to Fight Chronic Disease; and Henry Community Health.)