Care Transitions-A Community Based Partnership

About the Program

Category: Human Services (Best in Category)

Year: 2015

Mecklenburg County Department of Social Services - Community Resources Division (CRD) and Services for Adults Division (SFA) and in collaboration with the Mecklenburg Community Resource Connection (CRC), our Area Agency on Aging, and local hospitals, Carolina Healthcare System (CHS) and Novant, as well as Chronic Care Network of Greater Mecklenburg (CCPGM) have worked together for three years on how to improve Care Transitions from the hospital to the community. The goal of the Care Transitions initiative is to reduce 30-day inpatient readmissions and repeated Emergency Room visits for those with co-morbidity diagnoses such as Congestive Heart Failure, Diabetes, Chronic Obstructive Pulmonary Disease. Participants received supportive services by a DSS Social Worker, medication reconciliation and options counseling, along with the core services of in home aide, home bound meals and transportation for 30 days at the average cost of $700/individual. The program’s target population is for those 55+, Mecklenburg County residents, who have co-morbidity diagnosis and risk factors of living alone or with limited caregivers, but also have mobility and/or cognitive limitations.