TROY – Transition care is a phrase that followers
of health care news can expect to hear more and more
about. It is the process by which patients are moved
(transitioned) through the health care system from one
level of care to another as their individual needs require.
Transition care is especially critical for patients
with chronic diseases such as diabetes, congestive heart
failure and COPD. Because of their age or other barriers,
these patients often find it difficult to self-manage
their condition, resulting in high hospital readmission
rates and repeat emergency department visits.
FirstHealth of the Carolinas, which has had a transition
care component to its home health program for several
years, took the concept to a different level of service
with the opening of a Transition Care Clinic (TCC) on
the campus of FirstHealth Moore Regional Hospital in
Pinehurst last fall. A recent grant from the Health Resources
and Services Administration (HRSA) of the U.S. Department
of Health and Human Services (DHHS) will now allow FirstHealth
to open similar clinics in Montgomery, Richmond and Hoke
The total value of the three-year grant, made through
HRSA’s Small Health Care Provider Quality Improvement
Grant Program, is $450,000.
The first of the three clinics is scheduled to open
in March in the Medical Arts Building adjacent Montgomery
Memorial Hospital. Clinics will follow in Richmond and
According to Roxanne Elliott, policy director of FirstHealth
Community Health Services, the project has two goals:
to help patients learn to self-manage their disease and
to create a chronic disease care model that can be implemented
within FirstHealth primary care practices.
“We want to see what will work in rural, small
health care situations,” Elliott says. “We
will be looking for doctor and patient feedback in terms
of clinical outcomes and quality of life.”
The TCC in Troy will serve patients on Tuesdays and
Thursdays from noon to 5 p.m. Teresa Hunsucker, R.N.,
will continue her current role as Montgomery Memorial’s
transitions nurse for advanced heart failure and Emergency
Department patients while also coordinating services
for the new clinic.
In addition to FirstHealth services, she will also be
able to connect patients with appropriate non-hospital
“We want to make lowly motivated patients become
highly motivated patients so they become better self-managers,” Elliott
According to Beth Walker, president of Montgomery Memorial
Hospital, patients will be seen in a TCC within 48 to
72 hours of their discharge from any FirstHealth hospital.
Referrals can be made by either a hospitalist or emergency
Each patient will be assessed for a variety of services
that include health coaching, medication assistance,
respiratory therapy, home health, behavioral care and
tobacco cessation to make sure they are on track with
their prescribed plan of care.
“Our goal is to keep them from going to the emergency
room or being readmitted to the hospital,” Walker
While all hospital-discharged patients are eligible
for the 30-day service, patients with chronic disease
will make up the targeted population and the primary
care provider will always be a member of the health care
Walker predicts the TCC program will ultimately benefit
the entire community as primary care professionals become
educated on the transition care model and begin offering
transition-type services in their offices.
“We want to change the way health care professionals
work with patients,” she says.