Wake County’s Collaborative Approach to the High-Risk and High-Need

The Wake County Medical Society-Community Health Foundation (WCMS-CHF) was established as a 501(c)(3) in 2000. The two main service programs administered through it are Community Care of Wake and Johnston Counties (CCWJC) and the Capital Care Collaborative (CCC). CCWJC, established in 2003, is one of the 14 local networks of a statewide program, Community Care of North Carolina (CCNC), and seeks to improve access to and continuity, quality and coordination of care for Medicaid, Health Choice, select Medicare and other populations.

To achieve these goals, CCWJC works closely with primary care medical homes and their patients, provides data and analytics to guide population health activities, links major segments of the local healthcare systems (hospitals, public health, primary care providers, pharmacies, specialists, behavioral health providers, social services, community resources, etc.) and provides multidisciplinary care management for high-risk patients that includes nurses, social workers, pharmacists, physicians, a dietitian and a chaplain. Currently there are 160 primary care medical homes and 115,542 patients in Wake and Johnston counties as part of the CCWJC network.

CCC, established in 2006, is a national leader in demonstrating how competitive health systems can work together to improve health outcomes and lower the costs of care for the low-income uninsured community in Wake County. Partner organizations include area hospitals, Wake County Human Services and Wake County’s safety-net health clinics. CCC allows partner organizations to provide medical care to the uninsured in a coordinated fashion, while facilitating ongoing communication, assessment of community health needs, identification of priorities and initiation of working partnerships among providers. The CCC program provides multidisciplinary care management for uninsured individuals with chronic health conditions, mental health and substance abuse conditions, homelessness and chronic pain, and works to connect patients to primary care and behavioral health services as well as reduce emergency department visits and hospital admissions. Through the program Project Access, CCC also links uninsured patients with donated specialty and diagnostic care.

Advanced-practice paramedic (APP)/community paramedic programs, as part of an overall mobile integrated healthcare practice, have developed in North Carolina and several areas of the country. The Wake County APP program has existed since 2009 and has been a leader of this model of care in North Carolina. APPs have an enhanced level of training beyond that of basic paramedics. In Wake County APPs attend an in-house education program consisting of more than 200 didactic hours, 128 clinical hours and ongoing clinical education.

Due to their advanced training, APPs can provide a range of services to patients with a variety of physical and behavioral health conditions. APPs have the ability to address a patient’s needs in their home or, if appropriate, transport them to the best-suited level and most consistent site of care. APPs can respond to emergencies when needed (cardiac arrest, multiple-patient incidents, etc.) and perform minor medical procedures, laboratory services and immunizations. In addition, APPs can complete injury risk assessments and referrals, home-safety assessments, fall prevention and assessment, and social evaluations. They can provide assistance in hospital discharge follow-up, chronic disease care, medication compliance and administration. They can facilitate hospice coordination and prevent revocation and EMS utilization for terminal patients. In addition they can perform mental health assessments, including medical clearance to prevent unnecessary ED use; incorporate crisis intervention teams as needed; administer naloxone; and redirect care for people with mental health or substance abuse crises to facilities other than emergency departments.

Currently the Wake County EMS system uses 14 specially trained APPS and two APP supervisors who supplement the critical care response and serve as in-field resources to direct and coordinate the most appropriate care to patients. Up to five APP response units operate at the busiest times of day.

Whole-Person Orientation

There is a growing recognition that patient-centered care needs a whole-person orientation and that patients, particularly those with the most complex health conditions and high healthcare service utilization, may have a wide range of physical health, behavioral health and socioeconomic needs. Gaps in coordination of services for complex patients can lead to high-risk situations and poor health outcomes, but can be lessened by strengthening the collaboration between community-based healthcare professionals. The partnership between the multidisciplinary care management teams of CCWJC and CCC and the Wake County APPs is an example of this type of collaboration.

The care management teams of CCWJC and CCC utilize data and analytics to identify and prioritize the target population; serve the holistic, educational and self-care needs of patients and families; and make links to and coordinate needed medical care and community services. The APPs deliver rapid in-home, hands-on assessment and care and can respond to after-hours and urgent needs. Further, the APPs are able to intervene and immediately address unforeseen gaps in postdischarge plans identified by care managers. For example, the APPs have been able to address glucometer malfunctions and gaps in medication availability that occurred after-hours and during holiday times.

A specific area of focus has been patients with behavioral health, substance misuse/abuse and chronic pain issues, often with multiple emergency department (ED) visits and hospitalizations. The teams meet on a regular basis with local ED representatives to develop a plan of care on shared patients. These collaborative meetings include identifying high-risk patients, assessing barriers to appropriate care and solidifying a comprehensive approach to patient care management. These meetings also allow for bidirectional referrals, planning of joint home visits, and the development of standardized care plans for patients with frequent ED and EMS use and those at high risk for unintentional overdose. This collaborative effort was derived from the basic tenets of Project Lazarus, a community and statewide response to addressing chronic pain management and the epidemic of prescription pain medication use, overuse and unintentional deaths.

As part of this collaboration, a data-sharing arrangement has been developed between the agencies to improve patient care, assure quality and reduce costs. The data-sharing agreement has allowed the APPs access to the CCNC Informatics Center, which contains patient-level data on utilization history, medication history, laboratory data, primary care and specialist providers. Through this shared data system, outreach and interventions with patients are documented and shared between the CCWJC/CCC care managers and the APPs. In addition, complex patients, common to each program, have detailed shared care plans that include elements such as appropriate interventions for chronic conditions, flags for high-risk physical health or behavioral health conditions, high-cost healthcare utilization patterns, and a “destination plan” that designates one medical facility within Wake County where the patient will be transported, if transported by EMS. A consistent ED destination is a way to increase continuity of care, knowledge of the patient’s past treatments and medications, and patient safety.

CHF Patients

We are building on our success and have begun work on a collaborative approach to transitional care for congestive heart failure (CHF) patients. CCWJC CHF care managers identify patients’ needs based on both acuity and hospital readmission risk. For those who need a high level of immediate, in-home, hands-on service, an APP referral is made. The APPs can meet the patient at the hospital, complete a home visit the day of discharge to review discharge instructions, complete a medication reconciliation, check vitals and provide necessary disease education. This timely follow-up serves as a bridge to service and allows for seamless transition in patient management with a joint follow-up home visit between the APP and a CCWJC care manager. The CCWJC care manager can then provide ongoing comprehensive care management with the patient.

Recent work with a patient illustrates this new element of our collaboration. CW is a medically fragile patient with CHF and a history of multiple hospital readmissions. Through work with the patient, the CCWJC care manager learned CW was experiencing episodes of confusion in the evening, which was contributing to her medication nonadherence and threatening her overall safety. The Wake APPs were contacted to provide enhanced in-home assessment and support. They conducted an initial home visit and communicated details back to CCWJC through our shared documentation system.

The next day, as a plan of care was being jointly developed, a call was dispatched through EMS requesting a response to this patient’s residence. The same APP was able to respond to the call and assist with the transport. Although it was determined that the patient’s condition did warrant a hospital admission, the increased knowledge the APP had about this patient’s health history helped to inform hospital personnel and influenced the course of treatment and subsequent disposition planning. As a result of this collaboration, a robust discharge plan was formulated that involved multiple agencies, including the APPs, primary-care provider, CCWJC and home health.

This collaboration has been instrumental in ensuring accurate information is being communicated across all the agencies involved and a comprehensive plan of patient care is being utilized by all the patient’s care providers. Our collaboration on this patient and others continues to evolve as we draw upon the strengths and expertise from both organizations with the overall goal of improving patient care and outcomes, decreasing ED and hospital utilization, and decreasing healthcare costs.

Jamie Philyaw, MSW, received her Master of Social Work from East Carolina University. She is currently the Behavioral Health Program Manager for Community Care of Wake and Johnston Counties. In this role she works closely with community health partners to develop and implement integrated care activities to assure better health outcomes for patients. Jamie joined Community Care of Wake and Johnston Counties (CCWJC) in 2007.

Michael Bachman, EMT-P, is chief of clinical affairs for Wake County EMS, where he is responsible for clinical quality, performance improvement, research and data analysis. In addition he oversees the advanced-practice paramedic program. Bachman has been a paramedic since 1994 and served in various roles, including field training officer and clinical educator. He holds a bachelor’s degree in EMS and a master’s in health science, both from Western Carolina University.

Benjamin Currie, EMT-P, currently serves as a district chief for the Wake County EMS advanced-practice paramedic program in Raleigh, NC. He graduated from the inaugural APP academy administered by the county six years ago and spent three years functioning in the street as an advanced-practice paramedic. Since being promoted to supervisor, he serves as a front-line asset to He also works with program managers within the community who serve high-risk patient populations to coordinate and facilitate care and increase collaboration between multidisciplinary agencies and develop/coordinate targeted responses to reduce EMS/ED utilization when appropriate.

Robin Reed, MD, MPH, graduated from the University of Arkansas for Medical Sciences and completed a psychiatry residency, community psychiatry fellowship and Master of Public Health at the University of North Carolina-Chapel Hill. She is board-certified in psychiatry and provides care in the UNC Health Care system. She also serves as network psychiatrist for Community Care of Wake and Johnston Counties. Her clinical, administrative and scholarly work focuses on the integration of care for individuals with multiple complex chronic conditions.

Elizabeth Cuervo Tilson, MD, MPH, graduated from Johns Hopkins University School of Medicine and completed a pediatric residency at Johns Hopkins Hospital and a preventive medicine residency and Master of Public Health at the University of North Carolina-Chapel Hill. She is board-certified in pediatrics and preventive medicine, provides primary care in the Wake County Human Services Child Health Clinic, and serves as the medical director of Community Care of Wake and Johnston Counties. She works to support local systems of care and promote innovative strategies to improve the coordination of care for high-risk patients with chronic illness.