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CATCH of Central North Carolina

CATCH of Central North Carolina

Subtitle
Care Transitions to the Community and Home

Care Transitions to the Community and Home (CATCH) is a hospital-to-home transitions program for Medicare patients discharged to home with or without Home Health services.

Medicare Patients who qualify are assigned a CATCH “Transitions Coach” (RN) who will take primary responsibility for managing patient care post- hospital discharge.

Medicare Patients who participate receive the following interventions:

  • F/u phone call within 72 hrs. from an RN  who will determine if the patient has successfully filled all prescriptions and is taking medications as prescribed
  • Assistance with connecting to all f/u medical care and community resources
  • Disease specific education with emphasis on “Red Flags” to prevent readmissions
  • RN home visit for those not receiving skilled HH services.
  • Additional Support Services (meals, transportation/and or in-home companion services) .
  • Transitional Care follow-up for 30 days post d/c based on motivational interviewing techniques centered on patient goals to improve chronic disease self-management.

Inclusion Criteria

  • Medicare Part A and Part B insurance
  • Discharged to home, regardless of whether patient has home health
  • Residence in one of the 11-county region:   Durham, Franklin, Granville, Person, Vance, Warren,  Alamance, Orange, Chatham, Johnston, and Wake

Must have at least one of the five target conditions:

  1. Heart failure (or history of heart failure)
  2. Acute myocardial infarction
  3. Pneumonia
  4. Chronic obstructive pulmonary disease
  5. Diabetes

Exclusion Criteria

  • Primary diagnosis of a psychological condition
  • Dually eligible for Medicare and Medicaid
  • Enrolled in Medicare Advantage Plan
  • Discharged to skilled nursing or long-term care facility
  • Enrolled in a hospice program