APRIL 2015
BRIDGES TO HEALTH DEMONSTRATION PROGRAM
Federal Authorization:
State Authorization:
N/A
Session Law 2013-360 Section 12A.2. authorized funding for grants
nonprofit organizations providing services on a statewide basis
supporting State health and wellness initiatives including advocacy
and supports for individuals with intellectual and developmental
disabilities or severe and persistent mental illness, substance abusers,
or the elderly; and the provision and coordination of services for the
homeless.
N. C. Department of Health and Human Services
Office of the Secretary
Agency Contact Person –
Program and Financial:
Javier Rivera (Financial)
(919) 855-4862
Javier.Rivera@dhhs.nc.gov
Sherrie Settle (Program)
(919) 855-4804
Sherrie.Settle@dhhs.nc.gov
N. C. DHHS Confirmation Reports:
SFY 2015 audit confirmation reports for payments made to
Counties, Local Management Entities (LMEs), Boards of
Education, Councils of Government, District Health Departments
and DHSR Grant Subrecipients will be available by
mid
September
at
the
following
web
address:
http://www.ncdhhs.gov/control/auditconfirms.htm. At this site,
click on the link entitled “Audit Confirmation Reports (State Fiscal
Year 2014-2015)”. Additionally, audit confirmation reports for
Nongovernmental entities receiving financial assistance from the
DHHS are found at the same website except select “NonGovernmental Audit Confirmation Reports (State Fiscal Years
2013-2015)”.
Brief Description of Program:
The Bridges to Health program is an interdisciplinary drop-in group medical appointment (DIGMA)
coupled with proactive care management that focuses on low-income, uninsured patients who have
had multiple emergency department or inpatient encounters in the last year. Bridges offers an
alternative medical home with integrated drop-in group medical visits for one hour twice a week at
TFC, Blue Ridge Community Health Services, and Hendersonville Family Health Center, for a total
of six DIGMA sessions weekly. The care team includes a physician, nurse case manager, and
behavioral health provider. Additional care team members include an occupational therapist,
PharmD, and psychiatrist in order to provide a comprehensive model of care to a patient cohort
presenting a broad array of diagnoses and risk factors. To encourage attendance and healthful
behavior, patients are given a $5 certificate for a healthy meal, as well as a pass if they use public
transportation. The care team “huddles” prior to and after each group visit to review each patient’s
care plan. The group visit includes time for each patient to share with the group, as well as individual
time for health issues. The RN case manager contacts each Bridges patient weekly to check-in and
manage their care and is available to Bridges patients via cell phone M-F, 8:00am-5:00pm. The RN
case manager also holds a weekly Recovery Group meeting, as does the occupational therapist.
After-hours care is offered by each of the partnering practices and coordinated by the Bridges RN
Case Manager. A grant of $74,798 was awarded to the Henderson County Free Medical Clinic, Inc.,
for this purpose.
Organizations Funded:
E
[X] Private
[ ] Local Government
Short-Form-279
[ ] Both
1
A
Source of Funds:
C-4
Bridges to Health Demonstration Program
State __100%_
Short Form-X
Federal ______
2