Community Care Plan of Eastern Carolina (CCPEC), the regional Community Care of North Carolina (CCNC) affiliate, supports and promotes the patient-centered medical home (PCMH) model of care. Our Quality Improvement (QI) team is dedicated to helping primary-care medical practices coordinate and manage their N.C. Medicaid and Health Choice patients’ care in a PCMH setting, to improve patient outcomes while controlling healthcare costs.
CCPEC’s QI Practice Support is built around three major components:
Medical Practice Support
Our QI Practice Support Team partners with regional AHECs (Area Health Education Centers) to support the state AHEC system’s work with medical practices. The CCPEC QI team also provides consultation and training in several practice-redesign areas, including:
- Use of the CCNC Informatics Center (IC) and Provider Portal
- Patient-satisfaction assessment and improvement
- Clinical pharmacist consultation
- Reducing non-emergency patient hospital ED use, and inpatient readmission
- Implementing team-based care
- Addressing workflow challenges
- QMAF, or quality measures and feedback, supplied to practices toward improving both quality and cost of care for Medicaid recipients
Our QI Practice Support Team provides:
- Practice-specific data from Medicaid claims, chart reviews, and other sources to help medical practices identify needs and target areas for improvement
- Performance-measurement and feedback to help promote a practice’s continuous quality improvement
- Data to promote population-management strategies targeting those patients most likely to benefit
QI (Quality Improvement)
Our ongoing work in reviewing and monitoring our own case-management documentation and care-processes. We do this not only to provide better, more efficient, more cost-effective care, but also to maintain the necessary standards to ensure continued accreditation in Case Management through the National Committee for Quality Assurance (NCQA).
Among the ways our QI Practice Support helps practices achieve high-quality, cost-effective, patient-centered care is by linking them to our CCPEC team, which focuses on several key areas for improvement:
Below are a few of the specific QI initiatives we’ve developed within each of those key areas for improvement:
- Coordinated Care: Evidence-based care management that helps patients receive coordinated care and needed services
- Transitional Care: Helps practices manage patient care and reconcile medications after a patient’s hospital discharge
- Disease Management: Identifies patients with high-cost chronic conditions that significantly impact quality of life, and provides the patient with disease-education and follow-up
- SBIRT (Screening, Brief Intervention, Referral to Treatment): An evidence-based primary-care model for identifying, treating, and referring patients with, or at-risk for, alcohol or drug-use problems
- Primary-Care Integration: Integrating behavioral healthcare into the primary-care setting, and helping to manage patients with behavioral health needs
- Depression Toolkits for Primary Care: Using evidence-based tools to identify and treat depression in the primary-care setting.
- Patient Support: Helping patients as needed with completion of advanced-care planning documents.
- Practice Support: Helping medical practices upload advanced-care planning documents into a patient’s electronic health record (EHR)
- Outpatient Pharmacy Services: Education and implementation assistance on medication policy changes and initiatives (e.g., A+ Kids, Narcotic Lock-in, Preferred Drug List, etc.)
- Medication Management: Comprehensive medication reviews to improve global patient outcomes and decrease overall healthcare costs
- Community Pharmacy Partners: Transforming care-coordination to improve quality of care and patient outcomes related to medication use
- CC4C (Care Coordination for Children): Care management for children ages 0-5 targeting high-risk conditions, including exposure to toxic stress
- Health Check Coordinators: An outreach program to raise rates of well-child exams and vaccinations
- Pediatric Developmental Screening: Ensuring developmental screening, referral, and follow-up
- Oral Health: Dental-varnishing education and training; supporting access to “dental homes,” the dental equivalent of the PCMH
- Pregnancy Medical Home Program: Provides coordinated, evidence-based maternity care-management to pregnant women at risk for poor birth outcomes
- Collaborative Partnership: A partnership between OB practices, local health departments, and CCPEC
To meet the Community Care Plan of Eastern Carolina (CCPEC) Quality Team, go here.