Intentional collaboration: addressing transitions in care for people with severe and persistent mental illnesses

This commentary explores transitions in care for people who have severe and persistent mental illnesses and reside in long-term care communities. Challenges and historical approaches as well as barriers to successful transitions are examined. Recent policy changes in North Carolina are discussed and contextualized in emerging evidence-based practices that emphasize intentional collaborative efforts.     

Linking primary care with adult care homes

This commentary describes a pilot program wherein a community health center is partnering with Community Care of North Carolina to create a system of integrated care management and "treatment-in-place" visits for aged residents and disabled residents of adult care homes, with the goal of improving the quality of care and reducing unnecessary visits to emergency departments.     

Improving care transitions means more than reducing hospital readmissions

Hospital readmissions are not only expensive, avoidable, and dangerous, but are also indicative of the most dysfunctional elements of US health care. The Patient Protection and Affordable Care Act places great emphasis on reducing preventable readmissions by building care systems that are patient-centered and that remove arbitrary silos of care. Hospitals that perform poorly on this measure will experience significant financial penalties beginning this fiscal year. In the short term, decreasing readmission rates will eliminate waste and enhance patient recovery from major illness. However the real vision is to ensure that vulnerable patients, particularly the chronically ill, benefit from coordinated, patient-centered systems that maintain functional independence, improve quality of life, and provide comfort without the trauma, expense, and displacement that unnecessary hospitalization often entails. The commentaries published in this issue of the NCMJ portray some of the most significant barriers to smooth transitions and reducing readmission rates and describe some of the nascent North Carolina and national solutions that demonstrate promise in real world situations.     

The Pregnancy Medical Home: use of the power of the Medicaid program to improve the standard of care across North Carolina

The Pregnancy Medical Home (PMH) is a value-added, quality metrics-driven clinical program to improve the perinatal outcomes for pregnant women across the state of North Carolina. The PMH uses modest financial incentives to improve access to care, in a team approach led by obstetricians and supported by integrated aggressive care and case management.     

Practices to improve transitions of care: a national perspective

Improving transitions of care has significant importance to our health care system. While care transitions has been studied and researched by many individuals over the past 20 years, more work is needed to further improve the process. Those beginning to focus on transitions need not begin from scratch, but can use information and research from national and regional collaborative models, as well as other tools and resources to enhance the quality of transitions programs.     

Health and safety on North Carolina farms

Many rural areas in North Carolina do not receive the professional health care they deserve. North Carolina Farm Bureau recognized this unfilled need and implemented its Healthy Living for a Lifetime program in 2010. This initiative is one way to help improve the health of the state's 52,000 family farmers.     

The role of free dental programs in care provision for the underserved

Due to the shortcomings of the existing healthcare delivery system in general, and the dental field in particular, safety net programs are not simply optional; they are mandatory to help meet the overwhelming healthcare needs of the underserved. Free dental clinics are a vital part of this system, and indeed, millions of actual dollars, millions of dollars worth of services and thousands of hours of professional manpower are donated each year to provide free dental services for the needy. The short-term benefits of these clinics are obvious, the rendering of dental care to tens of thousands of individuals per year who would otherwise go without. The long-term advantages may be somewhat less than obvious, however. Given that most dental professionals have limited contact with the underserved, the free clinics offer the opportunity to bring in volunteer dentists, hygienists, and dental assistants who may then gain first-hand knowledge of the access crisis and work directly with North Carolina's growing population in greatest need of dental care. Additionally, the free clinics often offer the same benefit for dental students from the University of North Carolina at Chapel Hill, as well as for undergraduate pre-dental students. This is a key aspect, as for every one of these students who may eventually enter the dental profession with a willingness to provide for the underserved population, tens of thousands of individuals in need could potentially receive dental treatment over the span of a dental career. The challenges of beginning and maintaining a free dental program over the long term are daunting. However, for those willing to invest the time and effort, the resources are available for long-term success with a resultant significant, positive impact on the dental care access crisis now in existence. As stated by Dr. Franklin M. Boyar in describing his free dental program in Florida, "Project: Dentists Care is simply an organization that brings together unmet health needs of indigent populations within our communities with the desire of individual dentists to help their fellow man, along with the responsibility of a profession to deliver needed care to the underserved." Inherent in consideration of itself as a profession is the understanding by the component members of dentistry that it is indeed a responsibility, not simply an option, to deliver needed dental care to all citizens, regardless of their ability to pay. At the heart of any successful resolution of the dental care access crisis is the ability of dental providers to accept this responsibility, significantly increase Medicaid acceptance, willingly participate in access initiatives, and provide the care for which they have been granted licensure by the citizens of North Carolina.     

Economic impacts of Medicaid in North Carolina

OBJECTIVE: The purpose of this study is to provide estimates of the economic impacts of Medicaid program expenditures in North Carolina in state fiscal year (SFY) 2003. STUDY DESIGN: The study uses input-output analysis to estimate the economic impacts of Medicaid expenditures. DATA SOURCES/STUDY SETTING: The study uses North Carolina Medicaid program expenditure data for SFY 2003 as submitted by the North Carolina Division of Medical Assistance to the federal Centers for Medicare and Medicaid Services (CMS). Industry structure data from 2002 that are part of the IMPLAN input-output modeling software database are also used in the analysis. PRINCIPAL FINDINGS: In SFY 2003 $6.307 billion in Medicaid program expenditures occurred within the state of North Carolina-$3.941 billion federal dollars, $2.014 billion state dollars, and $351 million in local government funds. Each dollar of state and local government expenditures brought $1.67 in federal Medicaid cost-share to the state. The economic impacts within North Carolina of the 2003 Medicaid expenditures included the following: 182,000 jobs supported (including both full-time and some part-time jobs); $6.1 billion in labor income (wages, salaries, sole proprietorship/partnership profits); and $1.9 billion in capital income (rents, interest payments, corporate dividend payments). If the Medicaid program were shut down and the funds returned to taxpayers who saved/spent the funds according to typical consumer expenditure patterns, employment in North Carolina would fall by an estimated 67,400 jobs, and labor income would fall by $2.83 billion, due to the labor-intensive nature of Medicaid expenditures. LIMITATIONS: Medicaid expenditure and economic impact results do not capture the economic value of the improved health and well-being of Medicaid recipients. Furthermore, the results do not capture the savings to society from increased preventive care and reduced uncompensated care resulting from Medicaid. ConclusionS: State and local government expenditures do not fully capture the economic consequences of Medicaid in North Carolina. This study finds that Medicaid makes a large contribution to state and local economic activity by creating jobs, income, and profit in North Carolina. Any changes to the Medicaid program should be made with caution. RELEVANCE: The rising costs of health care and the appropriate role of government health insurance programs are the object of current policy debates. Informed discussion of these issues requires good information on the economic and health consequences of alternative policy choices. This is the first systematic study of the broader economic impacts of Medicaid expenditures in North Carolina.     

Reducing North Carolina's health care costs through environmental disease prevention

At a time of unprecedented pressure on the North Carolina state budget, reducing environmental risks to health may provide opportunities for substantial savings in the proportion of the state budget (24%) that is allocated for medical assistance. Recently, the Research Triangle Environmental Health Collaborative held a summit to identify options for increasing attention to environmental impacts on health in the ongoing health care and budget debates. Summit participants included not only public health and environmental experts, but also individuals (such as transportation planners, developers, and industry representatives) whose decisions can have a significant impact on environmental quality. This article summarizes key recommendations from the summit, as well as commentaries in the policy forum of this issue that further elaborate on why environmental quality matters for public health in North Carolina. Key recommendations from the summit include requiring formal health impact assessments (similar to environmental impact assessments but with an emphasis on health) in state and local transportation and land use planning processes, quantifying the total disease burden attributable to environmental hazards in North Carolina, prioritizing environmental risks to health in North Carolina, providing state technical assistance for communities disproportionately affected by poor environmental quality, establishing a new database system to link existing environmental and public health data by geographic location, undertaking North Carolina case studies to test the hypothesis that improving environmental quality also reduces medical care costs, and developing "environment matters to your health" public awareness campaigns.     

Psych NP-NC: a benchmark graduate nurse practitioner program for meeting the mental health needs in North Carolina

UNC-Chapel Hill's Psych NP-NC program prepares clinically and culturally proficient nurse practitioners to provide psychiatric and mental health care in North Carolina areas that are medically underserved and have a greater number of health disparities. This article reviews the program and the role of its graduates and makes policy recommendations for improving mental health care in the state.     

The role of allied health in health care reform

The wide-ranging and significant disciplines representing allied health constitute the largest and one of the most rapidly growing health care workforces in North Carolina. With anticipated increases in patients' access to care, allied health professionals will need to call on their full scope of practice as part of a comprehensive health care team.     

Access to dental health care for children in North Carolina

A significant number of children experience dental caries and have low dental care utilization rates. This article examines trends in oral health care access in the nation, as well as potential barriers, and finally, methods to increase access in North Carolina.     

Facilitating self-management of diabetes through education: the North Carolina case

Self-management education is such a critical part of diabetes care that medical treatment without it is considered inadequate. This article discusses the North Carolina Diabetes Education Recognition Program and calls for expansion of this program through local health departments.     

Newborn screening in North Carolina: the evolution of policy and practice

Newborn screening policies in North Carolina are due to the efforts of skilled and knowledgeable state officials, clinicians, and scientists who are able to develop effective newborn screening procedures. A newborn screening that was developed in North Carolina is the first automated method for diagnosing phenylketonuria. This process was later adopted in many other states. The use of tandem mass spectrometry in newborn screening was also pioneered in North Carolina, and it is being used in an increasing number of states. Newborn screening is more than testing, however; follow-up and specialized care are essential. State-level policies should recognize the multiple links necessary to make newborn screening effective and efficient.     

Making nurses full partners in redesigning health care in North Carolina

The Institute of Medicine of the National Academies recommends that nurses take a lead in reforming health care but recognizes significant barriers to nurses assuming such roles. In North Carolina, nurses must be on hospital boards, active in health policy debates, and empowered at the bedside and must lead financial decisions that improve care and keep hospitals financially viable.     

Use of telepsychiatry to improve care for people with mental illness in rural North Carolina

Telehealth improves access to medical services, especially for people living in rural areas. In North Carolina, the advantages of telepsychiatry also go beyond improving access. This article describes a diverse program of telehealth and telepsychiatric service delivery and discusses its advantages and disadvantages.     

Use of health information to improve care: the Southern Piedmont Beacon Community Grant

In 2009, the Office of the National Coordinator for Health Information Technology solicited proposals to participate in the Beacon Community Program. The program is designed to support communities with established reputations for adopting health information technology solutions. This commentary reviews Community Care of Southern Piedmont, a Beacon Community Program in North Carolina.     

Opportunities in preventive oral health care for children in North Carolina

Tooth decay affects more children than any other chronic infectious disease, yet it is almost entirely preventable. The Oral Health Section of the North Carolina Division of Public Health stresses the importance of prevention and promotes opportunities for citizens to achieve good oral health as part of total health.     

Regional extension coordinators: use of practice support and electronic health records to improve quality and efficiency

The North Carolina Regional Extension Center for Health Information Technology provides onsite consultation to primary care practices to help them implement electronic health records then use these systems to optimize care through measurement, rapid cycle quality improvement, and application of medical home functionalities. Services are available from all 9 regional North Carolina Area Health Education Centers.