Duke Endowment Grant Supports Work of FHC Transition Care Clinic

Patients who are referred to the FirstHealth Transition Care Clinic at FirstHealth Moore Regional Hospital are seen by Daniel R. Barnes, D.O.; and Cheryl Batchelor, ANP-BC. The clinic recently received a two-year $171,000 grant from The Duke Endowment to help fund its work.

PINEHURST – When Southern Pines resident Tom Worth needed advice about adapting to his just-diagnosed case of diabetes, the staff of the FirstHealth Transition Care Clinic was available to help.

Adult nurse practitioner Cheryl Batchelor, ANP-BC, R.N., examined him and decided that he needed diabetes education and home health assistance to help him deal with the sky-high blood sugar level that had put him into the hospital for more than two days last fall.

Now Worth keeps a journal of his blood sugar readings and what he eats to help keep them down. In addition, he and wife Mary Jo are for the first time in their long marriage reading food labels and taking stock of the proteins he needs and the carbohydrates he needs to avoid to stay healthy.

Both are grateful for the help the Transition Care Clinic staff has provided.

“I think they’ve got a good thing going with that transition thing,” the 85-year-old Worth says.

“It’s a tremendous asset,” says his wife.

The help Worth has received through the Transition Care Clinic (TCC) has so far allowed him to avoid the hospital readmissions and emergency department visits so common among people with chronic diseases like diabetes, COPD and congestive heart failure. The clinic recently received a two-year $171,000 grant from The Duke Endowment to help fund its work.

A foundation established in 1924 by industrialist and philanthropist James B. Duke, The Duke Endowment serves the people of North and South Carolina by supporting programs of higher education, health care, children's welfare and spiritual life.

In addition to Batchelor, the TCC is staffed by Dan R. Barnes, D.O., a board certified specialist in internal medicine who is also president of the FirstHealth Physician Group. According to Dr. Barnes, the clinic supports the work of primary care providers by giving patients the resources and information they need to help self-manage their disease.

All patients who are discharged from Moore Regional Hospital after a chronic illness-related admission are assessed for potential 30-day TCC participation.

“Many of our community physicians have utilized the TCC for patients who require dedicated teaching and close follow-up,” says Dr. Barnes. “The patients have been very appreciative of the time that we have been able to spend with them. It has been very rewarding providing patients with the necessary resources to truly understand their disease and take an active role in managing it. We are making an impact on some of the most vulnerable patients in our health care system.”

The TCC’s multidisciplinary team approach (involving health coaches, nutritionists, diabetes educators, pharmacists, and behavioral health and palliative care professionals) builds on FirstHealth’s successful system-wide program of transition care (the seamless moving of patients from one health care setting to another). Targeted success measures for the program include a reduction in re-hospitalization and emergency department use rates for patients with chronic disease as well as improved quality of life.

After their TCC care, patients are “transitioned” back to their own primary care provider for their long-term primary care needs.

Chris Miller, administrative director of FirstHealth Community Health Services, describes the process as a “bridge of comprehensive care” that extends from hospital to home.

“The needs of individuals, especially the underserved, living with chronic diseases, including those related to health literacy, depression and a lack of resources, are well-known, and the consequences of these needs are far too common in our region,” Miller says. “Other individuals lack the knowledge, skills or resources to comply with physician orders, follow medication regimens or make disease management-necessitated behavior changes related to tobacco use, diet or physical activity. Therefore, a bridge of comprehensive care via the Transition Care Clinic from hospital back to home provides a significant opportunity to improve the overall health of our community.”

Located in the Specialty Centers Building on the campus of FirstHealth Moore Regional Hospital, the FirstHealth Transition Care Clinic is open Mondays, Wednesdays and Fridays from 8 a.m. to 5 p.m. and Tuesdays and Thursdays from 8 a.m. to noon. Patients are seen by physician referral.