FHC to Open Transition Care Clinic for Chronic Disease Management

Cheryl Batchelor, ANP-BC, R.N.

Daniel R. Barnes, D.O.

PINEHURST – It’s difficult to determine who bears the greater burden in the matter of hospital readmissions involving patients with chronic disease – the patient dealing with the stress and frustration of frequent hospitalizations or the hospital facing the expense of high-cost revolving-door medical care.

According to national research studies and quality-reporting programs, 15 to 20 percent of the people who are discharged from the hospital will be readmitted in 30 days or less and many of the readmissions could have been prevented. Most of these patients are dealing with the long-term effects of such ailments as congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes or coumadin therapy – or a combination of problems.

Hospitals have found that one of the best ways to reduce health care costs and improve patient care in the process is to introduce services designed to reduce chronic disease readmissions. FirstHealth of the Carolinas will introduce such a service next month with the opening of the FirstHealth Transition Care Clinic (TCC) on Oct. 1.

The program’s director is Cheryl Batchelor, ANP-BC, R.N., an adult nurse practitioner with an extensive background in cardiothoracic nursing and nurse leadership. She describes the FirstHealth TCC as “the blueprint for clinics of the future” because of its multidisciplinary focus on the outpatient management of patients with chronic disease.

“Our focus is on transition care,” she says. “Our role is really what the title implies.”
Located in the FirstHealth Specialty Centers Building at 35 Memorial Drive, Pinehurst, the TCC will be open Mondays, Wednesdays and Fridays from 8 a.m. to 5 p.m. and Tuesdays and Thursdays from 8 a.m. to noon. Patients will be seen by physician referral.

According to Batchelor, the clinic is intended to serve as a bridge from hospital to home to help prevent readmissions after a recent hospital discharge or return visits to the emergency department. A patient can be seen in the clinic for up to 30 days after the hospital or emergency department discharge.

Although every referred patient will be seen in the TCC within 48 hours to seven days of discharge, Batchelor expects some patients will average two or three additional visits within the 30-day treatment window.
“The goal will be to ensure that our patients have a well-developed treatment plan and that they stay in compliance with that plan,” she says.

Patient referrals can be made through a variety of sources: by a physician in the hospital (either an emergency department physician or a hospitalist) or by the patient’s primary care provider.

Medicare and most insurance policies will pay for TCC care, and self-pay patients will also be accepted.

In addition to Batchelor and a certified medical assistant, the FirstHealth TCC will be staffed by Daniel R. Barnes, D.O., president of the FirstHealth Physician Group. A specialist in internal medicine and hospital medicine, Dr. Barnes regards the TCC as another resource in FirstHealth’s continuum of care for patients with chronic diseases.

“Transition Care Clinic patients will have access to a large multidisciplinary team providing services that could include IV diuretic therapy, health education and coaching, nutrition counseling, medication review and reconciliation and, if needed, assistance with financial issues,” he says. “We also anticipate adding other resources to our team as needs are identified and volumes necessitate them.”

According to Batchelor, the TCC will enhance, but not replace a patient’s relationship with his/her primary care provider. “Our program is intended only as a bridge from the hospital stay until the patient stabilizes in the home environment,” she says, “so our staff will communicate with the patient’s regular provider with updates on treatment, medication changes and other services.”

Batchelor joined Moore Regional Hospital in 1990 as a cardiothoracic nurse specialist responsible for the development of orientation and training of intensive care nurses for the hospital’s then-new cardiac surgery program. She later served in a variety of nurse leadership roles.

A BSN graduate of the University of North Carolina at Chapel Hill, she earned her master’s degree in nursing from East Carolina University and an adult nurse practitioner post-master’s certificate from Duke University. Board certified as an adult nurse practitioner, clinical nurse specialist and nurse executive by the American Nurses Credentialing Center, she is also a Healthcare Executive Fellow of the American College of Healthcare Executives.