New pilot program to provide transitional care following hospitalizations to North Country Medicaid patients


WATERTOWN, N.Y. (WWTI) — A new pilot program will aim to provide intensive support to medicaid patients following hospitalizations.

Little mTCM, or Medicaid Transitional Care Management is being launched by a group of North Country Initiative primary care partners. The program is modeled after a similar service for medicare patients where those discharged from hospital care are given services specific to their needs, a care manager and more information to help their needs.

According to North Country Initiative Deputy Director Joanna Loomis, these programs have had significant benefits for Medicare patients both locally and nationally.

“We’ve seen the post discharge hospitalization readmissions and the total cost of care decreased significantly,” stated Loomis. “So in other words, patients who get discharged from the hospital and they get a [transitional care management] service they fare much better in the 90 days after they’re discharged than patients who don’t get it.”

Program leaders agree that this pilot could not be more timely. During the COVID-19 pandemic, those requiring hospital stays were sometimes prohibited from having support persons, family and friends. Leading to feelings of isolation and anxiety.

North Country Initiative Medical Director Dr. Steven Lyndaker and Loomis commented on the effects this has had on patients and how the program will mitigate these issues.

“We know very clearly that anxiety levels and stress levels interfere with healing,” stated Dr. Lyndaker. “

Loomis added, “what this does is it sort of surrounds the patient with support, and particularly if the patient was in the hospital alone, think about how confusing sometimes that situation may be. And when you’re receiving discharge instructions, you might not be able to really fully internalize those.”

This program has the ability to benefit a significant portion of the North Country. According to the U.S. Census American Community Survey, over 58,000 individuals in Jefferson, Lewis, and St. Lawrence counties have Medicaid coverage; approximately 25% of the population.

And overall, according to both Dr. Lyndacker and Loomis, the pilot will help to improve the quality of care North Country Medicaid patients receive and reduce costs by connecting key community players such as transportation, nutritionists and lifestyle coaches.

“As we see the data, we know how much those social determinants of health really do affect your, your A1C, weight, blood pressure; everything that’s coming through in the vitals in an office visit is very intimately related to those,” expressed Loomis.

Relating to social determinants discussed by Loomis, Dr. Lyndaker further explained “If you can do all of that within the context of a need, like post hospital issues needs, post emergency room visit needs, that’s the secret sauce. I think it gives us all incentive to want to participate.”

The first of its kind, Medicaid Transitional Care Management pilot program is officially being launched on April 1, 2021. Eligible patients will be contacted by the North Country Initiative.

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