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Care Transitions Project

Care Transitions Project

Subtitle
Care transitions to the community & home

Community Health Partners is currently working in partnership with CaroMont Hospital and CMC-Lincoln hospital and a Care Transitions Coalition to address 30-day hospital readmissions focusing on the Medicare, low-income, or the uninsured at-risk population. The NC Hospital Association sponsored this initiative to get us started. Over 50 people attended the first Coalition meeting held in March. There was much discussion about the role of the community in preventing hospital readmissions. A lack of critical and timely community supports, such as meals and transportation were identified as needs following discharge.

There are now four work groups with a goal to implement a pilot project in the next twelve months. The hospitals will be responsible for identifying the target population who are at the highest risk of readmission; the community volunteers will take responsibility for the follow-up care with those targeted patients. A volunteer and faith-based community effort will be developed in each county building from a very successful model operating in Memphis, Tennessee. The individual who developed the Memphis model happens to live in Winston-Salem. There is much development work ahead for the work groups. We will keep you posted on the progress.