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Community Care of North Carolina CCC Transitional Care Management Jennifer Cockerel, RN, BSN, CDE Director, Chronic Care Programs & Quality Management1Chronic Care PopulationWithin the NC Medicaid
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Step 1: Obtain the ccnc transitional care management form.
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Step 2: Start by providing patient information such as name, date of birth, and contact details.
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Step 3: Fill in the patient's medical history, including any known allergies, chronic conditions, and previous treatments.
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Step 4: Document the reason for transitional care management, explaining the need for ongoing care and the desired outcomes.
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Step 5: Provide a detailed medication list, including dosages and frequency of administration.
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Step 6: Note any existing care plans or referrals to specialists.
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Step 7: Specify any additional care or assistance required during the transitional period.
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Step 8: Review the completed form for accuracy and completeness.
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Step 9: Submit the filled-out ccnc transitional care management form to the designated authority or healthcare provider.

Who needs ccnc transitional care management?

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Patients who have recently been discharged from a hospital and require ongoing medical care.
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Patients with complex medical conditions or multiple chronic diseases.
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Patients who need assistance in coordinating their healthcare services.
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Patients who are at a higher risk of readmission or complications after discharge.
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Patients who would benefit from comprehensive care management during the transition from one care setting to another.
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CCNC Transitional Care Management (TCM) is a program designed to improve the coordination of care for patients transitioning from a hospital or skilled nursing facility back to their home.
Healthcare providers, such as physicians, nurse practitioners, and physician assistants, are required to file CCNC Transitional Care Management.
Healthcare providers can fill out CCNC Transitional Care Management by documenting the patient's medical history, conducting a face-to-face evaluation, creating a care plan, and providing necessary follow-up services.
The purpose of CCNC Transitional Care Management is to reduce hospital readmissions, improve patient outcomes, and enhance the coordination of care between healthcare providers.
Information that must be reported on CCNC Transitional Care Management includes the patient's medical history, current health status, care plan, and any follow-up services provided.
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