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2017 NC Care Transitions Summit

February 2, 2017 @ 8:45 am - 4:00 pm

The 6th annual NC Care Transitions Summit, Moving Forward Improving Care Transitions Together was our biggest Summit yet! Community providers, hospitals, long-term care, home health, hospice, government programs and others from across the state interested in strengthening care transitions met in Durham for learning, collaborating and networking. With almost 350 in attendance the day was a hit! Thank you again to our sponsors for the summit!

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Detailed Agenda


Summit_KRask_HighlightKeynote – Paying for Quality Health Care Across the Continuum
Speaker: Kimberly J. Rask, MD, PhD, Chief Data Officer, Alliant Health Solutions

Dr. Rask reviewed new incentive and penalty programs from the Centers’ as well as alternative payment models designed to reward physicians, long-term care providers and hospitals that work together to coordinate care for the patients that they share.
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Plenary Panel: Medication Sustainability Post-Discharge and the Important Role it Plays in Reducing Readmissions
Speakers: Moderator – Jennifer Hodge, RN, MSBA, HIIN Quality Specialist, Alliant Quality; 
Shakeerah McCoy, MSN, RN, PCCN, Clinical Nurse Specialist, Transitional Care Program, Nash, UNC Health Care; Ouita Davis Gatton, RPh, Patient Care Coordinator, The Kroger Company; Gina Upchurch, RPh, MPH, Executive Director, Senior PharmAssist; Winnie Walker, RN, BSN, CCM, ACM, Emergency Room Case Manager, Duke Raleigh Hospital; Kathy Reese, RN, Case Manager, Community Care of the Lower Cape Fear; Christina Nunemacher, PharmD, Clinical Pharmacist, Realo Discount Drug; Michael Crooks, PharmD, Care Coordination Task Lead, Pharmacy Interventions Technical Lead, Alliant Quality

*No presentation for this session

AM Breakout 1: The North Carolina Way – Early Data from Faith Community and Health System Partnerships
Teresa Cutts, PhD, Asst. Research Professor, Wake Forest School of Medicine; Beata Debinski, MHS, Research Assistant, Wake Forest School of Medicine; Gary Gunderson, MDiv, DMin, VP of Faith Health, Wake Forest Baptist Medical Center; Jeremy Moseley, MPH, Director of Community Engagement, WFBMC; Rev. George Dean Carter, MDiv, Southeastern Regional Medical Center; Lisa Marisiddaiah, RN, Faith and Health Ministry Manager, CaroMont Health; Barry Morris, MDiv, BCC, Director of Spiritual Care and Community IntegrationRandolph Hospital; Renee Rutherford, RN, FaithHealth and Readmissions Coordinator, Wilkes Regional Medical Center

This panel presentation presents findings from a learning collaborative of Wake Forest Baptist Medical Center and six other health systems who have partnered with faith communities to improve care for their vulnerable populations. This work, funded by The Duke Endowment, Kate B. Reynolds Charitable Trust and Northwest AHEC, has explored the impact of faith community partnerships on charity care costs and readmission times at seven hospitals located in both rural and urban parts of the state. Additionally, the project has tested partnership assumptions and characteristics thought to have been responsible for the success of the Memphis Model (a partnership of Methodist Le Bonheur Healthcare and over 600 mostly African-American churches), which was led by Rev. Dr. Gary Gunderson, who was recruited to WFBMC to adapt the model to NC.
Presentation (PDF)

AM Breakout 2: North Carolina State Health Plan Enhanced Transition of Care (TOC) Program
 Keya Brooks, MBA/MHA – Network Manager, ActiveHealth Management; Kathryn Keogh, PhD, MSN, RN – Health Systems Clinical Coordinator, State Health Plan; Heema Sinanan, Project and Operations Manager North Carolina Hospital Association (NCHA) Strategic Partners

ActiveHealth Management (AHM) provides full population health management services, including transition of care services, to North Carolina State Health Plan (Plan) members who are active, COBRA, or pre-65 retirees. The population targeted for the Enhanced Transition of Care (Enhanced TOC) Program includes members that are at high risk for avoidable readmissions. The focus of our Summit presentation was to discuss the purpose, implementation, and impact of the Plan’s Enhanced Transition of Care Program as well as continued efforts to achieve program goals. Presentation (PDF)

AM Breakout 3: The Healthy Aging NC Resource Center: A Vision of the Future
Jeanne Dairaghi, Chronic Disease Self Management Program Manager NCCHW’s Healthy Aging NC; Nicolle Miller, Director of State and Community Collaboration NCCHW’s Healthy Aging NC

The Healthy Aging NC Resource Center is a project of the North Carolina Center for Health and Wellness (NCCHW) at UNC Asheville. Our mission is to be a leader and trusted partner in the state to help people meet the challenges of aging. We work with nonprofit organizations, government, clinicians, and businesses to provide innovative community programs and services that meet the needs of North Carolina Older Adults and Adults with Disability. Our current focus is on Evidenced Based Programs for Fall Prevention and Stanford’s Chronic Disease Self Management Programs. This presentation was an overview of the Healthy Aging NC Resource Center, key partners, ways to become involved and create connectivity across the state. Explanation on how the Healthy Aging Resource center and Healthy Aging NC website can be implemented in the area of Care Transitions.
Presentation (PDF)

AM Breakout 4: COPD Readmission Reduction Pilot
Sejal Patel, MD, Utilization Management Physician Advisor, New Hanover Regional Medical Center; Laura Warrick, RN, Manager of Clinical Services, New Hanover Regional Medical Center Home Care; Tony Bollhorst, RT, COPD Navigator, New Hanover Regional Medical Center; Pam Hagley, RN, BSN, MSHA, ACM, Director, Clinical Resource Services, New Hanover Regional Medical Center

Why is it important? Starting October 2014, the hospitals had to pay a penalty for readmissions under HRRP for COPD readmissions. The HRRP is a reimbursement penalty approach for general acute care hospitals that have readmissions deemed “excess” by CMS. Beginning fiscal year 2013 (October 1, 2012). Reduction is capped at 1% in 2013, 2% in 2014 and 3% in 2015 and beyond. Reductions apply to total DRG reimbursement.
Presentation (PDF)

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Lunch Session: Transitioning Home: Improving the Process for Individuals Needing Long-Term Supports

This lunch option featured a facilitated conversation with fellow professionals passionate about person-centered transitions and quality transitions practices for individuals needing long-term services and supports.  During this lunch, participants received an update on where the State of NC is on projects, initiatives, and policy specific to transitions work. Participants also helped identify what’s missing and what shouldn’t be overlooked to ensure quality person-centered transitions are a reality in every transition.  The NC Community Transitions Institute supported by the NC Department of Health and Human Services’ Money Follows the Person Demonstration Project is sponsored this luncheon.
Presentation (PDF)

PM Breakout 1: Readmissions: Moving from Data to Patient Engagement
 Carolyn Bowen, RN, BSN, Readmission Coordinator, Department of Care Coordination, Wake Forest Baptist Health; Linda Childers, MSW, LCSW, ACM, Manager, Department of Care Coordination, Wake Forest Baptist Health; Alisha T. DeTroye, MMS, PA-C, Director of Transitional and Supportive Care Director of PA Services, Wake Forest Baptist Health

This session did an overview of changes in the health care environment, highlighting the shift from episodic care delivery of services to the current model involving linkages to community based partners. Common barriers to the achievement of patient centered care were outlined with strategies to address them shared. The work of a readmission coordinator, operating in a transitional care model, including the analysis of data collected from patient interviews, was discussed.
Presentation (PDF)

PM Breakout 2: HOPE: Easing the Transition from Duke University Hospital to Skilled Nursing Facilities
Heidi White, MD, MHS, MEd, Associate Professor of Medicine, Geriatrics Division, Duke University Department of Medicine, Medical Director of HOPE; Tammie Shepherd, MHA, BSN, RN, ACM, Director Case Management Department Duke University Hospital; William English, MBA, MSHA, Administrative Manager Duke Palliative Care, Administrator HOPE, Duke University Hospital

At Duke University Hospital, geriatric patients being discharged to skilled nursing facilities (SNF) have been identified as high risk for readmission to the hospital. A program to improve post-discharge outcomes for this group is the Health Optimization Program for Elders (HOPE).
Presentation (PDF)

PM Breakout 3: Moving Forward Together: Partnering with Your Area Agency on Aging for Effective Care Transitions
Sara Melton, AAA Director Southwest Commission Area Agency on Aging; Linda Miller, MA, Centralina Area Agency on Aging Director; Julie Wiggins, AAA Director High Country Area Agency on Aging

Did you know there are 16 Area Agencies on Aging in North Carolina? Area Agencies on Aging (AAA) have been in existence for over 50 years and have long been established as the “go to” organization in the Aging Network for assistance and information, training, advocacy and direct services. This session will explore the ways that your local AAA can help to both collaborate and provide services such as Money Follows the Person, Chronic Disease Self-Management, Options Counseling, Home and Community-based Services, and community education. Learn about how strong community partnerships between your organization and your local AAA can be at the core of successfully transitioning the elderly client across the various levels of care and reduce the risk of readmission.
Presentation (PDF)

PM Breakout 4: Uniting Advance Care Planning Conversations between NC Healthcare Providers and the Community
Linda Darden, MHA, CPA, President & CEO Hospice & Palliative Care Center; Adam Koontz, MA LPC-S Corporate Manager of Advance Care Planning, Novant Health

The mission of the NC Partnership for Compassionate Care (NCPCC) is to ensure that patients’ end-of-life care choices are openly discussed, documented, and honored. In addition this collaboration aims to provide educational resources to the community and health care professionals to improve the quality of care at the end of life. Attendees will learn about current initiatives at the statewide level to promote greater utilization of the MOST and other advance directives. The Community Partnership for Compassionate Care and the Got Plans? training resources will also be shared as an example of community organizations and healthcare systems working in collaboration at a regional level to advance the understanding and acceptance of advance directives. Our aim will be to inform the attendees on the role of NCPCC in coordinating and disseminating information about the MOST and other advance directives, and to share examples of collaborative efforts.
Presentation (PDF)

Plenary Panel: The Vital Role Care Coordination Plays in Transitions of Care for Patients with Behavioral Health Needs
Moderator: Julia Wacker, MSW, MPH, VP of Community and Behavorial Health, North Carolina Hospital Association; Stacy A. Smith, LPC-S, CS-I, LCAS, NCC, Adult Mental Health Lead, Community Services and Support, NC DHHS; Lisa DeCiantis, MA, LPC, Adult Mental Health Program Coordinator, Division of Mental Health, NC DHHS; Erin Myer, LCSW, Director of Behavioral Health, Gaston Family Health Services; Brad Owen, LPA, Director of Specialized Community Services and Supports, Vaya Health; Jerry Earnhardt, MS, LPCS, LPC, Regional Operations Director, Daymark Recovery Services; Jennifer McLucas, MHA, MSW, LCSW, LCAS, Director, Home Health and Residential Services, WakeMed Health and Hospitals 

*No Presentation for this session

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NCACT would like to thank the following organizations for Sponsoring the Summit!

Level 1 Sponsor:

NC DHHS’ Money Follows the Person Demonstration Projectscreen-shot-2017-01-12-at-11-13-17-am

Level 2 Sponsors:

Alliant Quality Alliant Logo

6Sigma Tek          6Sigma - Logo 2014

Novo Nordisk            NovoNordisk_Logo

Cipher Health CipherHealth logo-no background

Level 3 Sponsor:

Brian Center Southpoint  brian-center-logo

Level 5 Sponsor:

Insight Medical           InsightMedical_Logo


February 2, 2017
8:45 am - 4:00 pm
Event Category:


Durham Convention Center
301 West Morgan Street
Durham, NC 27701 United States
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