CCNC will provide analytical tools through its advanced informatics systems and statewide healthcare management information system.
Community Care Partners of Greater Mecklenburg (CCPGM), one of CCNC’s 14 networks based in Mecklenburg County and MeckLINK will collaborate on PROACT (Preventable Readmissions Options and Care Transitions) in providing transitional care and community resource linkage. This will be through an interdisciplinary team of nurses and social workers who will identify and promptly respond to dually-diagnosed patients in local hospitals and emergency departments. The team will connect high-risk/high-cost patients to appropriate outpatient care, assist with pharmacologic education and needs, and support collaboration between behavioral healthcare providers and the patient’s primary care medical home.
The team will engage patients through hospital, community, and home visits as well as telephonic follow-up. Currently, only 42% of North Carolina Medicaid patients discharged from a psychiatric inpatient facility sees an outpatient clinician within 90 days of discharge. Lack of community follow-up can lead to repeated medical and mental health crises and potentially avoidable emergency room visits and hospitalizations. CCPGM will work closely with local medical and mental health providers to develop care protocols for this population and work to improve integration and awareness between medical and mental health professionals. This improved collaboration between behavioral health and medical professionals is expected to significantly improve patient care and help restrain Medicaid costs.
CCNC is a community-based, public-private partnership. CCNC takes a population health management approach to improving access, linking resources and health care, and containing costs for North Carolina’s most vulnerable populations. Through its 14 regional network partners, Community Care ensures “medical homes” for Medicaid beneficiaries, individuals eligible for Medicare and Medicaid, privately insured employees and uninsured people in all 100 North Carolina counties. CCPGM is the local CCNC network providing team-based care management to 168,000 residents of Mecklenburg, Union and Anson Counties.
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Contact: Gary Black at 704-336-3354 or Gary.Black@MecklenburgCountyNC.gov