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Community Medical Clinic of Kershaw County helps reduce hospital re-admissions

Posted: January 4, 2018 11:24 a.m.
Updated: January 5, 2018 1:00 a.m.
Provided by the CMC/

Stacy Branham, a registered nurse case manager at KershawHealth and Debbie Davis, also a registered nurse and community care coordinator at CMC, review case files to make sure patients without insurance admitted into KershawHealth get the follow-up care they need.

Navigating a trip to the hospital can be challenging, especially if you’re doing it without insurance.

Thanks to the Community Medical Clinic of Kershaw County (CMC), there is a Transitional Care Program to help individuals without insurance receive follow-up care after and avoid being readmitted to the hospital.

“The first 30 days is a critical benchmark,” said Stacy Branham, a registered nurse case manager with KershawHealth. “(This program) creates a medical home for these patients. They are able to stay at home and recover, and they now have a primary care doctor to assist them in getting the care they need without being readmitted to the hospital. We’re already seeing the impact here. It’s huge.”

So far, 67 patients have been a part of the transitional care program. Thirteen of those clients were readmitted to the hospital, and five were readmitted with a different diagnosis.

“While these numbers look good and save taxpayers money,” said Holly Hayes, an improvement advisor with Iron Sharpens Iron consulting group. “It means even more to the people the program helps.”

There has been a 25% decrease in ER visits for non-emergency purposes that can be directly attributed to the work of CMC, Hayes said. One ER visit for a patient without insurance usually costs more than $1600. A hospital admission can be upwards of $28,000. 

The Transitional Care Program is a collaboration between CMC and KershawHealth. Community care coordinators, registered nurses employed by CMC, visit KershawHealth and meet with patients who don’t have insurance and also don’t have primary healthcare providers.

“Being there and meeting face-to-face makes a big difference,” Debbie Davis, CMC community care coordinator, said. “We get to connect with the patients, hear their story and then connect them with the resources they need. This is much more personal than a follow-up phone call. It allows us to really get to know each patient.”

Community care coordinators explain that CMC can provide medical care to Kershaw County residents without insurance at no cost. Patients can then fill out a CMC application and schedule a follow-up appointment.

“The Community Care Coordinators make a big difference,” said Judy Hall, an RN case manager with KershawHealth. “They get here before the patient leaves and offers them the opportunity to get primary care face to face. It’s not a blind, cold-call after the fact or them being handed a telephone number they should call. It’s a person in front of them showing kindness and compassion.”

This program was piloted in June 2016, and in December 2016, began accepting all uninsured Kershaw County residents.

Launching the transitional care program was also an opportunity for CMC to implement a new clinical care model called Community Hub and Pathways.

This model helps to identify at-risk individuals and provides them with an effective, coordinated connection to medical and social services. This new model allows CMC to continue to provide high-quality services to those in our community who need it the most, as well as efficiently track and report outcomes for medical, social, and economic determinants.

“Basically, we’ll now be able to more effectively identify and track the impact of our services,” Susan Witkowski, CMC CEO said. “Traditional healthcare has relied on a reactionary system that delivers treatment in response to an urgent need. This model allows us to be more proactive and collaborative. The emphasis is on preventive care and how we can treat the whole person. The goal is to reduce medical costs while also providing a better service to our patients.”

The care coordination team under this new model consists of a nurse practitioner, community care coordinators, medical assistant, a community navigator and community health workers (CHW). This team actively collaborates in order to provide for both the medical and social needs of each individual.

CMC is embarking on its 20th year as a charitable family practice medical clinic. It was founded on the mission of providing medical care to the uninsured residents of Kershaw County. CMC has grown from seeing several patients a week in one room to having a fully staffed medical facility as well as mobile clinics. Today, CMC’s mission is two-fold. Ir provides primary care to patients at no cost, while also leading a collaborative effort to empower individuals to take charge of their own health and well-being.

Community support of CMC has allowed the organization to provide medical care for our neighbors who are underserved or uninsured. Today CMC plays an increasingly broad role as the leader of a collaborative effort to improve population health throughout the county. The clinic itself serves as the medical home to 800 county residents, resulting in about 3,600 patient visits annually.

To create a legacy for Kershaw County, contribute to CMC’s mission by visiting


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