Using Care Managers to Improve Patient Health Post-Discharge
Duke University Health System/Northern Piedmont Community Care
411 W. Chapel Hill Street, 3rd Floor
Durham, NC 27701
Since implementation of the care manager program, Northern Piedmont Community Care (NPCC) has seen an eight percent reduction in its 30-day readmission rate.
Duke University Health Systems’ Northern Piedmont Community Care is comprised of Durham Community Health Network and Community Care Partners. NPCC promotes wellness and strengthens the self-care capacity of Medicaid members and their families. NPCC is one of 14 statewide Community Care of North Carolina (CCNC) networks. It spans six counties and includes 55 primary care practices and five hospitals, reaching a patient population of over 70,000.
Quality Improvement Coordinator
Northern Piedmont Community Care
In an effort to reduce its 30-day readmission rate, Northern Piedmont Community Care implemented a nurse care manager program, which utilizes home visits with patients recently discharged from the hospital to make sure that a care plan is established and followed.
The process starts when patients who routinely use the emergency department or do not engage in their primary care are admitted to the hospital. At this point, the nurse care manager is alerted that the patient has been admitted to the hospital and upon discharge, the nurse care manager makes contact with the patient within seven days to connect the patient with her primary care doctor and any other social services she may need.
The nurse care manager makes a home visit. During the visit, the nurse goes over the patient’s medications, making sure he has the proper dosages and the necessary prescriptions filled. The nurse also discusses with the patient the proper way to manage his condition—when to take his medications, the recommended diet and exercise routine, and the necessary follow-up visits to his primary care doctor. The nurse discusses what led the patient to the point of hospitalization and the warning signs that their condition is worsening, which could lead to a return trip to the hospital. Finally, the nurse and patient set and discuss goals for the patient to achieve.
The home visits continue until the patient reaches a point where is empowered to manage her health effectively.
This proactive approach to the care transition process provides patients with direct access to the health care system and the resources they need to manage their conditions with success. The program itself is seeing success. Since implementation of the care manager program, Northern Piedmont Community Care has seen an 8 percent reduction in its 30-day readmission rate.
Poor care coordination contributes to the issue of avoidable readmissions.Learn more