Bridging the Healthcare Gap: An Effective Collaboration of Hospital Medicine and Community Case Management

1Community Case Management, FirstHealth Moore Regional Hospital, Pinehurst, NC

Meeting: Hospital Medicine 2008, April 3-5, San Diego, Calif.

Abstract number: 122


All too often the transition of patient care from the inpatient to the outpatient setting is a dilemma. Our hospital administration recognized this issue and developed a community case management program (CCMP). The staff hospitalists collaborated with the CCMP to identify at‐risk patients in order to provide needed resources, increased access to services, and avoid costs through unnecessary rehospitalization, emergency room encounters, and prolonged length of stay.


To describe the implementation of a CCMP in collaboration with a 385‐bed community, nonteaching hospitalist program.


Effective November 2007, the CCMP is open to patients with any chronic disease who would benefit from enrollment. The program offers a multitude of services, which include outbound calls to assess disease management, medication procurement and management, referral to community resources, health‐related education, and telehealth services. The CCMP targets patients who have had 3 or more admissions to the hospital for the same diagnosis within the last 6 months, those who cannot afford or self‐manage their medications, and most important, those with a clinical condition that may result in a high rate of recidivism if care were not managed. It was determined that the CCMP would provide a great service to the hospitalist program. Therefore, a collaborative agreement was reached wherein the hospitalists would refer at‐risk patients to the CCMP. Thereby, the 2 services work toward encouraging patient compliance and reducing unnecessary health care costs.


From November 2007 through December 2007, the CCMP has received 36 patient referrals; 18 (50%) were enrolled, of which 11 (61%) were hospitalist patients. The most commonly provided services to these patients have been disease management (100%) and medication assistance (64%). All the patients who have received medication assistance stated that they would not have been able to obtain their medications if the CCMP did not exist. Because their chronic disease would have been uncontrolled without these medications, the program was able to prevent these patients' readmission. Additionally, only 1 of the 11 patients has been readmitted to the hospital since the program's inception. In summary, the collaboration between the CCMP and hospitalist service has created a unified team to improve clinical quality and outcomes for the community while reducing health care costs to the patient and hospital organization.

Author Disclosure:

H. Taylor, FirstHealth Moore Regional Hospital, Employment.

To cite this abstract:

Taylor H. Bridging the Healthcare Gap: An Effective Collaboration of Hospital Medicine and Community Case Management. Abstract published at Hospital Medicine 2008, April 3-5, San Diego, Calif. Abstract 122. Journal of Hospital Medicine. 2008; 3 (suppl 1). Accessed March 29, 2020.

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