Granville Health System Receives $204,600 Grant from The Duke Endowment to Expand Transitional Care Program


OXFORD, NC (January 20 , 2017) – The Duke Endowment recently announced the Foundation generously awarded Granville Health System (GHS) a two-year, $204,600 grant to expand the Health System’s Transitional Care Program.

Granville Health System’s Transitional Care Program is the System’s program designed to ensure patients are adequately prepared for the transition from hospital to home by encouraging patient participation in post-discharge care. The Transitional Care Team ensures hospital patients have follow up appointments with their primary care physician, arranges for continued care where appropriate and even visits patients at home to assess their recovery progress after discharge and assist with understanding medications.

“Granville Health System began focusing on transitional care in 2012. With the leadership of our Board of Trustees and direction from our medical staff, the Transitional Care Team has developed an incredibly effective, programmatic approach to caring for our community,” said CEO L. Lee Isley. “Since that time, readmissions have remained low and increasingly improved as the program continues to grow.”

Recent reported readmission rates for GHS were 1.63%. This measure counts patients discharged that have to be readmitted to any acute care facility in North Carolina within 30 days after their initial discharge under the same condition. The North Carolina state average during this period was 3.32%. The performance rate for GHS is statistically significant, being approximately half the state average.

An important role of Transitional Care is facilitating the patient and their family's ability to manage care at home. Through referrals from our Transitional Care Program, Paramedics with Granville EMS, operating in an expanded role, use their existing training and skills to meet clinical needs of the patient outside of the hospital in a non-urgent setting. The Mobile Integrated Health Program focuses on improving the quality of care for the patient while reducing costs associated with preventable readmission.

“With the assistance of The Duke Endowment we now have the resources needed to expand the Mobile Integrated Health Program,” said Jason Brand, GHS Administrative Director, Emergency Medicine. “The grant assists in reducing health care costs, but also helps provide our patients with the resources needed to stay healthy. We want to keep folks from making unnecessary Emergency Room visits and ultimately avoid readmissions.”

The patient’s care team meets with the patient and their family prior to hospital discharge to develop a personalized plan of care that includes healthy goals aimed at preventing future hospital admissions. The Transitional Care team ensures hospital patients have follow-up appointments with their primary care physician or arrange for home health services.  

Granville EMS or Transitional Care nurses and social workers visit patients at home to assess their recovery. The Transitional Care Program allows for a more effective collaboration with all members of the patient’s healthcare team, more favorable patient outcomes and ultimately, drives down the overall cost of delivering medical services to the community.

In addition, the expansion of the program allows for Transitional Care to integrate into the primary care practices as Chronic Care Mangers (CCM) provide 1 on 1 consultation to patients to address self-management of care, medication compliance and to ensure all necessary services, resources and medical equipment is utilized. CCMs establish effective monthly care plans and monitor patients’ physical, mental and social conditions.

“It’s been a successful program,” said Wendi Yancey, GHS Transitional Care Director. “In 2015 our team made home visits to 30 patients. In 2016 the number nearly tripled to 86 patients. Without the resources provided through the grant, it would have been very difficult to meet the growing needs of our community.”

This innovative program, and its success, has caught the attention of many in the health care industry. If fact, the Transitional Care Program will be represented at the upcoming 2017 American Hospital Association’s Rural Health Care Leadership Conference being held February 5 in Phoenix, Arizona. Isley, Brand and Yancey have been selected to present “Transitional Care in a Rural Setting: Redesigning Hospital Discharge to Enhance Patient Care,” to a national group of health care leaders representing health systems throughout the United States.


About The Duke Endowment

The Duke Endowment is one of the largest private foundations in the Southeast. Its work in North Carolina and South Carolina focuses on four program areas: Child Care, Health Care, Higher Education and rural United Methodist churches.

The Endowment’s Health Care program area focuses on improved quality and safety of the delivery of health care, improved access to care, and enhanced prevention for improved population health. In North Carolina and South Carolina, candidates for grants include not-for-profit hospitals, academic health centers, area health education centers, select organizations in counties without an eligible hospital, and not-for-profit inpatient long- term care facilities.

The Endowment has distributed more than $3.3 billion in grants since its inception in 1924. The foundation shares a name with Duke University and Duke Energy, but all are separate organizations.


About Granville Health System

For more than 95 years, Granville Health System has been delivering quality health care close to home.  To meet the growing needs of our community, Granville Health System has expanded its services throughout Granville County, offering convenient access to medical care where you work and live. GHS received a number of national awards, including the Hospital of Choice Award which named Granville Health System as one of the top 100 hospitals in the country in 2009, 2010, 2011 and 2012. GHS also received the Community Value Index Five-Star Hospital Award, placing GHS in the top 20% of hospitals in the country in offering financial value to the communities served, while reinvesting back into facilities in order to provide for current and emerging health needs. Recently, the System was named one of the nation’s Top Performers on Key Quality Measures by The Joint Commission, the leading accreditor of health care organizations in America. For more information, please visit



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