Transitional care cut hospital readmissions for North Carolina Medicaid patients with complex chronic conditions

Medicaid populations are high-risk groups to care manage, particularly at transition points. Community Care of North Carolina (CCNC) was able to demonstrate sustained decrease in the readmission rates for this population with aggressive case management both telephonically and embedded in primary care; individuals in their transitional care group were 20 percent less likely to be readmitted within a year compared to similar patients receiving standard of care. One of every three readmissions was avoided for their highest-risk patients with complex clinical presentations. The essential elements of the program included medication management, education for patients and their familiar and a strong link to the medical home.