By Thomas Goldsmith


You’ve heard the stories: A friend’s mother comes home from the hospital, a home health nurse is set to visit the following day, but the visit never takes place. Or, a patient is sent home from the hospital with instructions to see their primary care doctor in the coming week, but the earliest appointment is weeks away. Before the appointment, the patient returns to the hospital.

The “continuum of care” often evoked by health care professionals as being best practice often looks more like a dotted line when seen in practice.

Gaps among locations and levels of care that can cause real problems for patients and institutions will be addressed in detail at the N.C. Care Transitions Summit, set for Feb. 2 at the Durham Convention Center. Presented by the N.C. Alliance for Effective Care Transitions, or NC ACT, the event examines the hard situations in which patients and clients can be left by the wayside.

Tortured transitions

Consider the situation faced by Rowan County community paramedics who wanted to arrange follow-up visits with people released from the hospital who were staying at a community shelter.

“They can’t conduct one-on-one visits at a community shelter; they don’t have the privacy, “ said Trish Vandersea, program manager for NC ACT. “That community paramedic program was able to go beyond the normal conventions and meet with that individual at the fire station,” which had been cleared for that purpose.

Academic research suggests that such “community paramedics” can help fill gaps in care when employed in conjunction with health care and social service agencies. Such community paramedic programs are becoming increasingly common across the state and nation.

“One gentleman had been in the hospital multiple times in the past 30 days,” and had not been taking prescribed medications, Vandersea said. “The paramedic was able to get him back to the hospital to have those medications filled.”

Creative solutions ease the way

NC ACT, funded by the Duke Endowment, operates under the umbrella of the North Carolina Quality Center, established in 2004 by the  North Carolina Hospital Association (NCHA).

Sometimes the solutions can seem ridiculously simple.

“One woman came in hundreds of times because she couldn’t control her diabetes,” said Julie Wiggins, executive director of the High Country Area Agency on Aging in Boone and one of the summit panelists. “It turned out she didn’t have a refrigerator in her house and she couldn’t keep her insulin cold.”

A driving force for strengthening the continuum of care has been the presence of penalties imposed by the Centers for Medicare and Medicaid Services against hospitals experiencing preventable readmissions. Next year, skilled nursing facilities, or nursing homes, will also be subject to these penalties.

That’s where innovations such as those seen in the High Country Area Agency on Aging come into play. Instead of simply operating a voucher program for respite care for its clients, the agency uses government funds to pay Brenda Reece, family caregiver support specialist, to run a sister not-for-profit organization, the High Country Caregiver Support Foundation.

As executive director, Reece writes grants and solicits contributions to the foundation, resulting in roughly twice as much funding — as much as $125,000 in a single year — in vouchers for caregivers of older adults.

“It enables them to have regularly scheduled time for themselves — they can go to doctors’ appointments,” said Reece, who said it’s hard to get families to identify when they need help. “That is what people do up there — they look after their families. Many of them wait until they are at their wit’s end to ask for help.”

Agencies often have to use creativity to find funding to bridge gaps in the continuum of care. The High Country Caregiver Foundation put on a “festival of tables” competition to raise money for respite vouchers. Photo credit: High Country Caregivers Foundation.

In addition to bringing in more funding, foundation staff make arrangements with providers to accept vouchers from clients. In other regions, caregivers often must pay upfront and file for reimbursement.

The $500 respite vouchers, available every six months, can provide adult day care, assisted living, home care or other means to provide breaks for stressed caregivers, lessening the likelihood that clients will end up in long-term care. To support the foundation, people in the seven counties that are part of the High Country AAA put on all sorts of fund-raising events.

“We do trivia challenges and the festival of tables, where people compete to decorate tables,” said Reece, who won a national Area Agencies on Aging Association award for her foundation work in 2015. “All the money stays in the county where it was raised.”

Another concept on the summit’s agenda, “patient engagement and activation,” also works toward smoothing transitions between levels of care. Using assessment tools, professionals can measure a  specific patient’s ability to understand, carry out and help guide the continuing treatment after discharge.

“People actively involved in their health care have better outcomes and lower cost,” Vandersea said.

Registration closes Thursday. Visit for more information.

What’s NC ACT?

“The North Carolina Alliance for Effective Care Transitions (NC ACT) is a gathering of stakeholders representing hospitals, long term care, assisted living, home health, hospice, palliative care, mental health, case management, insurance plans, community care networks, interfaith communities, senior services, patients and others meeting to coordinate efforts improving care transitions across all settings for all North Carolinians. Collectively NC ACT strives to combine resources and disseminate best practices to ensure North Carolinians are provided effective, person-centered, and optimal transitions of care.”



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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...