As a part of outreach efforts to chronically ill and unstable patients, Carolina Collaborative Community Care, Inc. (4C) provides a transitional care program for individuals discharged from in-patient facilities. The program is structured around interventions that ensure coordination and continuity of health care as patients transfer from the hospital to the community. Primary care managers partner with 4C hospital care managers to facilitate a positive outcome for transitioning patients without duplicating hospital discharge planning efforts. The primary goal is for the patient to have a successful discharge from the hospital or the emergency department to the home environment.
While in the hospital, the patient is visited by 4C hospital care managers. The hospital care managers perform medication reconciliations, provide education, and identify barriers to follow-up appointments and compliance. After identifying patient needs, care managers work with patients to establish relevant goals for self-maintenance after discharge.
After discharge from the hospital, patients are contacted by 4C primary care managers. The primary care managers perform a home visit to reconcile the patient’s discharge medications, assess the patient’s follow up appointment status, and provide further education as needed. Following the home visit, patients may be referred to community resources.