Clay County Medical Center (CCMC) has been recognized as a Health Quality Innovator of the Year recipient for 2024. This award recognizes organizations that are successfully using evidence-based approaches to improve healthcare quality in their communities.

CCMC’s Transitional Care Management (TCM) program was selected as a runner-up in the Population Health category for its work in improving the health of patients and communities through prevention, treatment, and improved access to health care.

Jeanette Collin, CCMC Patient Navigator and Social Worker, spoke about the TCM program.

“We were looking to try and help people stay out of the hospital to lower those readmissions. We were trying to figure out why they were coming back, and help them stay home. So, we started making phone calls to them within 24 to 48 hours after discharge.”

“We call to make sure that they picked up their medications, that they understand how to take them, make sure they know when their follow-up appointments are with their doctor or specialist, or if they have any lab work. Things like that.”

The program has improved the post-discharge follow-up rate by over 10% to an impressive 97.56%. CCMC is continuing to strive to make that 100%.

Collin said while this program has been highly successful, they are always looking for ways to improve.

“We are always looking to improve and that’s something that I always ask whenever I call. “How was your stay? Is there anything that you think we can improve on?” We take that very seriously and we are trying really hard.”

“I think the communication between the patient, ourselves, and the doctor’s office; I think that that’s the loop that needed to be closed.”

This innovator award showcases the TCM team’s commitment to using innovative practices to close the gap between discharge and follow-up care. Further providing high-quality care to their patients and the community.