PINEHURST — The Care Transitions Collaborative, administered by the North Carolina Quality Center and funded by The Duke Endowment, has awarded FirstHealth of the Carolinas nearly $300,000 over the next two years to help further develop the Complex Care Management Program of FirstHealth Care Transitions Services.
The grant is designed to help hospitals and outpatient providers improve care transitions for patients and caregivers.
Led by a registered nurse care manager and including a certified health coach, the Complex Care Management team provides holistic care management to help patients improve their disease self-management skills and quality of life and avoid unnecessary hospitalizations and emergency department visits.
Services will assist about 1,000 patients with heart failure, chronic obstructive pulmonary disease or diabetes who are at high risk of hospitalization.
“Many chronically ill patients, particularly those who have been in the hospital, are simply not able to effectively manage their complex conditions without intensive support,” said Patty Upham, director of FirstHealth Home Care and lead project director for the effort. “They are often overwhelmed with the hospital discharge instructions, multiple new medications and dietary restrictions. If we can provide targeted, patient-centered support and education, these patients can have a better quality of life and spend less time in the hospital.”
Dr. Dan Barnes, president of the FirstHealth Physician Group, echoed this sentiment.
“We care for patients every day who need a high level of support, education and encouragement as they figure out how best to manage their diabetes, heart failure or COPD,” he said. “With this project, thanks to the North Carolina Quality Center and The Duke Endowment, we now have the resources to give them that support right in their own homes.”
FirstHealth Care Transitions Services provides Home Health, Complex Care Management and telehealth services in Moore, Lee, Richmond, Montgomery, Scotland and Hoke counties.