Community C are of W ake & Johnston Counties

Improving Patient H ealth, Saving Medicaid H undreds of M illions of Dollars
Real E xamples from O ur Community

N W is a 12 year old girl with severe asthma that was requiring multiple Emergency Department (9 in 2 years)
and urgent clinic visits (6 in 2 years). A CCWJC Care Manager worked with her to link her to an accessible
primary care provider (PCP) and provide intense patient education on self-management and medication use. In
addition, CCWJC, in it’s partnership with Wake County Environmental Services, provided her an in-depth
home assessment for asthma triggers and resources to mitigate those triggers. After engagement with CCWJC
and her PCP, the patient’s asthma was in much better control, required fewer emergency department visits (only 
1 time in the 2 years after CCWJC engagement), and required fewer urgent clinic visits (3 times in 2 years after
engagement). As the quality and control of her asthma improved, the cost for her asthma care decreased from
$12,000 for the 2 years prior to engagement with CCWJC to $2000 for the 2 years after engagement with
CCWJC.

SS is a 51 year old woman with a history of a transient ischemic attack, hypertension, hydrocephalus with shunt
and revisions, cerebral aneurysm with coil repair, myocardial infarction, and anemia. She had 7 ED visits in
and 3 hospital admissions in one year. The total Medicaid cost for her care in one year was $11,576. A
CCWJC Case Manager began working with her, did a home visit with a CCWJC social worker, helped link the
patient with her PCP, and helped link her with mental health for therapy. Since then, she has had no ED visits
and only one recent admission. Her chronic diseases are so much better managed now that she is back in school
for her GED in order to enter the workforce.

R B is a 13 year old boy who had very poorly controlled insulin dependant diabetes. In one year, the child was
hospitalized 4 times for extended periods and had utilized the emergency room for uncontrolled diabetes 6
times. The child had been discharged from several physician practices due to non compliance and would go
extended lengths of time without seeing a physician or using his insulin. Care management through
Community Care began and provided home and school visits for in-depth educational sessions, referrals to
many community resources, including the Wake County EMS Advanced Paramedic Program, and extensive
follow up and communication with patient, family and all organizations involved in the patient’s care. The
patient is now well linked with a PCP, has improved compliance with medications, improved health outcomes,
and improvement in the patient’s psychosocial status. Improved outcomes and cost savings are evident in that
in the year following care management, the patient utilized the emergency room only one time and admissions
decreased to only two times.

L D is a 71 year old woman who came to a CCWJC Care Manager’s attention from a hospitalization and a 
referral from her PCP for issues of medication compliance. The Care Manager embedded in one of our
Federally Qualified Health Centers was able to meet with this client during two separate office visits. The Care
Manager reviewed medications with the patient and during the second review, discovered that the patient could
not read her medications bottles, although she stated she could. With the PCP’s advice, the Care Manager gave
the patient four pill boxes and arranged to have the patient come in to the PCPs office at least monthly for
assistance in filling her medication box by either the Care Manager or the Medical Assistant. LD has had
improvement of her medication compliance and is more adherent to her appointments with her PCP and
specialists.
 

L D is a 2 year old child diagnosed with De George Syndrome with history of developmental delay, heart failure
and aortic arch repair. In one year, LD had six hospital admissions, multiple ED visits for sick care, and several
missed primary care and specialist appointments. A referred was made to one of our bilingual Community Care
care managers. A home visit was made and the care manager identified multiple social issues and barriers to
care.  The parent was overwhelmed with the child’s challenging condition.  The family had a lack of resources
including, reliable transportation. The mother, whose primary language is Spanish, was intimidated by the
medical setting due to the language barrier. The care manager was able to facilitate a change of PCP to one
who was familiar with De George Syndrome, who spoke Spanish, and whose practice had broader Spanish
speaking capacity. Communication among outside agencies, specialists, and therapist was coordinated. In a
matter of months, the patient’s health began improving.  The patient learned how to stand and began learning 
how to eat. Hospitalization reduced to only one in the year following the initiation of care management. ED
visits were decreased and were only as a result of PCP referrals when a high level of care was needed.

M E is a 20 year old female young lady with a history of deep vein thrombosis and depression. She was
identified by Community Care due to frequent ED use and non-adherence to her medication and laboratory
monitoring regimen. For a 12 month period prior to care management, ME had 8 ED visits and a poor link with
her PCP and specialists. She often missed appointments to the point that she was discharged from her
Hematologist’s practice.  Upon engagement with the patient, the care manager recognized that, since a young
age, ME has had the responsibility of taking care of her sick mother, a child, and her own health needs, with no
family support. She was overwhelmed by these responsibilities and did not have the skills needed to follow
through with her medical regimen. With the support of care management, ME has only had 1 ED visit related
to a complication from the birth of her son. She is now well linked with her PCP and Hematologist. She gets lab
work every 2 weeks at her PCP office and is successfully managing her own medications including a
subcutaneous injection. This patient is also well linked to mental health services and does not have any ED
visits or hospitalizations related to mental health. She has increased social support and has been linked to Child
Service Coordination, Catholic Parrish Outreach and even had a group sponsor her family for Christmas. The
care management team helped her obtain discounted bus fare for public transportation to physician visits and
other needs. She is now in the process of finding employment and taking a much more active role in managing
her own healthcare needs.

Provider E xperience
"Joining CCWJC is the best thing we ever did for our practice" Gayzel Sevilla, Wakefield Peds & Adolescent
Medicine, 1062 Medicaid Patients (Feb 2011).

“Community Care has been a great help to our practice. Every person who works there is eager to help manage

even my most complicated patients. They have gone above and beyond to provide the best medical care while
trying to keep costs down. The patients who have been helped by the case managers are grateful. Often they
have no idea of how to navigate the system and the case managers are a wonderful help with that and getting
services set up. I wish all of my patients had access to this resource! In addition, with the guidance of the
leaders in Community Care, we physicians are shown better, more cost effective ways of managing our most
complicated patients. This is good for everyone. Please continue to fund this most necessary resource!”  Dr.
Beth Murnane, Sunrise Pediatrics, 382 Medicaid Patients (Feb 2011).