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facing that, as well. She said her depression was worsening, and she didn’t Monroe
care if she lived or died.
Our entire team came to know Monroe when he posted on
She met our nurse care manager, Paula, who was very concerned CCPGM’s social media page acknowledging the help he was
because she had seen patient-specific data (clinical and utilization patterns) receiving from our team-based approach to care. He is now
that indicated Frankie’s worsening health status. Frankie shared, “Paula serving on CCPGM’s Patient/Family Advisory Council to help
came into that visit and let me know my life is worth living” and never us ensure the patient’s voice is involved in our patient education
gave up on me. Paula coached Frankie through a plan that included diet, materials and program development. He also is interested in
exercise and diabetic management. Two years later, Frankie has lost 160 becoming a peer supporter – most likely helping to develop our
lbs., has brought her Hemoglobin A1c from 11.9 to 5.2 and is no longer virtual peer support capabilities.
on insulin. Also important, she now assists CCPGM as a peer supporter
helping others manage their diabetes. Her lived experience and health Clearly, this complex care management approach is effective in
improvement motivate our patients beyond what we can do alone. improving quality of life, managing health care cost and making the
best use of limited healthcare resources. Community Care Partners
José of Greater Mecklenburg, and more broadly, the 14 networks of
Community Care of North Carolina, continue to make progress on
On a home visit, 51-year-old José shared that he has had a “rebirth” improving quality of life through care coordination while decreasing
since working with our CCPGM social worker-nurse care manager team. overall healthcare costs.
He is a painter’s helper, who shared his story of coming home from work
one day and having most of his big toe slough off inside his sock. He knew About Community Care of North Carolina
he no longer could ignore his diabetes and needed some serious help. He
began a pattern of obtaining care in the ED and had unreimbursed costs of CCNC’s family of companies includes parent company CCNC, Inc. and
almost $300,000 in an 18-month period. North Carolina Community Care Networks, a community-based, public-
private partnership that creates “medical homes” in all 100 counties for
CCPGM team members Julia, a social worker, and Johanna, nurse North Carolina Medicaid recipients. The CCNC enterprise is dedicated
care manager, began working with José as part of a pilot to improve to innovative approaches to population management that improve health
care coordination for high-risk patients in September 2015. He credits and reduce costs, particularly for vulnerable populations. To learn how
his “angels” with saving his life. His ED visits have stopped, and José CCNC improves quality and saves millions of dollars every year, visit
is receiving regular care with his safety net primary care provider and a www.communitycarenc.org.
specialist. He avoided limb amputation and is able to work again.
Charlotte AHEC Course Offerings NC MedAssist Has Moved!
Charlotte AHEC is part of the N.C. Area Health Education Centers NC MedAssist is now at
(AHEC) Program and Carolinas HealthCare System. 4428 Taggart Creek Road #101, Charlotte, NC 28208
FEBRUARY 2016 Phone Numbers:
Continuing Medical Education (CME) Main Line: 704-536-1790
Toll-Free: 1-866-331-1348
2/6 Sanger Heart and Vascular Institute Pharmacy: 704-943-9639
Cardiovascular Symposium 2016
2/19-20 Utilization of Ultrasound in Obstetrics and Fax: 704-536-9865
Gynecology 2016
2/23 & 6/21 Quality Improvement 101 – Wave 14 Main Office Hours:
Online DOT Medical Examiners Course Monday to Friday: 8 a.m.–4:30 p.m.
Online Risk Management
Online Social Media: Risks & Benefits for Physicians Pharmacy Hours:
Online Prevention and Management of Concussion/ Monday to Thursday: 9 a.m.–5 p.m.
Mild Traumatic Brain Injury
Online Motor Vehicle Crash Victims Friday: 9 a.m.–2 p.m.
Closed Saturday and Sunday.
For more information or to register for these courses,
call 704-512-6523 or visit www.charlotteahec.org. To schedule a tour, ask general questions and give
comments, email info@medassist.org.
Mecklenburg Medicine • February 2016 | 7
