Resources

This second of three case studies examining key operational aspects of coordinated care initiatives in Medicaid focuses on the Transitional Care Program (TCP), part of Community Care of North Carolina (CCNC), the state Medicaid program’s medical home system. The Transitional Care Program provides robust discharge and transition planning for high-risk Medicaid inpatients, including aged and disabled beneficiaries and those with multiple chronic conditions, to arrange and support sound transitions of these individuals back to the community, and reduce the risk of emergency department use and hospital readmission. Transition planning revolves around the use of hospital-based care managers who coordinate with care managers in medical home practices; centralized health information technology that provides real-time data on Medicaid admissions to the hospital-based care managers, the CCNC regional networks, and practices; and standard care management training and tools statewide.