- Website URLhttp://www.carterethealth.org/
- Phone Number(252) 499-6000
Carteret Health Care (CHC) is a 135-bed nonprofit hospital serving the community in Carteret County, NC, since 1967. The Transitional Care Management (TCM) Department began at CHC in 2011. Since that time, the department has grown in staff and scope. We conduct home visits, assess for further discharge needs with our discharge phone calls, and promote interdepartmental communication to meet the unique needs of each patient.
How We Improve Care Transitions
TCM has partnered with our local Skilled Nursing Facilities (SNF) to promote smooth patient transfers from CHC to SNF. Each local SNF sent a representative to CHC for a week in January 2016 to conduct process analysis and collaborative problem solving to improve continuity of care for our patients. As a result of this effort, representatives were chosen from CHC and each local SNF to communicate the discharge process for each patient transitioning from CHC to SNF. Each business day, someone from the TCM contacts each SNF that received a patient the day before to assess for patient and provider needs.
TCM also provides phone calls to the vast majority of inpatient discharges within approximately 2 business days to evaluate for education needs and concerns. We confirm the arrival of DME in the home, initial contact to the patient by the home health agency (if ordered), confirm primary care provider follow-up appointment, and the successful pick-up and knowledge of new prescriptions.
Each of these patients is assessed for appropriateness and consent to participate in our Telehealth Program. The Telehealth Program provides vital sign equipment and scale to each patient with a 1 hour home visit by a Registered Nurse. The patients are taught to take their measurements each day, and the equipment communicates the vital sign and weight information to a Registered Nurse at the hospital who then follows up with a phone call, if necessary, to the patient. Patients are selected based on diagnoses for which daily vital sign monitoring is beneficial towards identifying concerning health trends such as, but not limited to, Pneumonia, Heart Failure, COPD, TIA, and Stroke.
Finally, since 2016, we have been a participant in the COMPASS study conducted by researchers at Wake Forest Baptist Medical Center (https://www.nccompass-study.org/). This study focuses on patients discharged to home or home with home health that have a new TIA or Stroke diagnosis while at CHC. Participants in this program are also offered the chance to participate in our Telehealth Program.
Patients, families, and caregivers
Primary Care Providers
Skilled Nursing Facilities
Home Health Agencies
Wake Forest Baptist Medical Center (COMPASS study)
How We Measure Our Efforts
Data has been collected for readmission rates prior to and after implementation of TCM interventions. We have seen a decrease in our readmission rate following these interventions. We also conduct root cause analysis of patient readmissions. Each readmission is assessed to ensure that patient needs are being met. After participating in the Care Transitions process, a survey is sent to the patient homes to collect their thoughts on staff engagement, helpfulness of the program, and overall patient satisfaction. This information is reviewed and combined with the readmission rate and root cause analysis data to help grow our program to a state that best serves our patients.
- Address3500 Arendell Street , Morehead City, North Carolina, 28557
- Mailing Adress
- Primary Contact NameBetsy Lane, BSN, RN, CDE, Director of Care Transitions and Community Health Programs
- Primary Contact Emailbolane@CCGH.org
- Primary Contact Phone(252) 499-6644