Community Care of North Carolina (CCNC) has conducted a detailed study of how to maximize the impact of
transitional care on readmissions and total cost of care. One of the findings was that transitional care
management has far greater benefits for patients with multiple chronic conditions than for patients with one or
no chronic conditions. Certain patients also benefit more than others from specific components of the
intervention including timely outpatient follow-up as well as home visits for medication reconciliation. This
session will describe how CCNC care managers are successfully using this information. Participants will
receive an understanding of how to target their work to reach recipients with the right transitional care
interventions to maximize patient benefit.
Carlos Jackson, Ph.D., is the Assistant Director of Program Evaluation, at Community Care of North Carolina. Dr. Jackson has over 15 years’ experience as a health services researcher, and has become a thought leader in how to maximize use of administrative data to answer timely policy relevant questions. Since joining Community Care of North Carolina, Dr. Jackson has been focused on evaluating the impact of transitional care management on patients discharged from the hospital. Analyzing data from CCNC’s care management information system and accompanying outcome data from paid Medicaid claims, Dr. Jackson has contributed greatly to the knowledge about what transitional care interventions work best and for whom. The knowledge developed from these evaluations have led to the creation of impactability scores for transitional care whereby individual patients are assessed in terms of their likelihood to benefit from a transitional care intervention. He has a strong track record of working closely with public health and mental health administrators at the national, state, and local levels to help them use data to inform decision making.
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