After launching the NC Integrated Care for Kids (NC InCK) model in our five-county service area in January 2022, we celebrated our first anniversary in 2023. More than 1,600 families have been engaged in the NC InCK model since Spring 2022, thanks to the incredible work of our partners. Among these families, 350 are children in foster care placements. In partnership with our five local Department of Social Services (DSS) offices, NC InCK works closely with foster families, as our model focuses on reducing out-of-home placements.
Area 1: Understand Needs
In 2022, NC InCK began using data and information to understand the needs of children and young adults. The model began using this same data to lift up children and young adults ages 0-20 for NC InCK’s integrated care model. NC InCK is now linking data across NC Medicaid, NC Department of Public Instruction, and NC’s Division of Juvenile Justice and Delinquency Prevention. Each month, NC InCK brings together the data across these three agencies to prioritize new children for engagement with the NC InCK model. This is the first time that data on health, education, child welfare and juvenile justice have been brought together to identify children for care management under NC Medicaid.
Area 2: Support and Bridge Services
Since 2022, 4,600 families have received outreach for NC InCK’s integrated care model, and 1,600 have chosen to engage in services. Families who engage in the model are paired with a care manager who works with their primary care practice. Setting goals for an NC InCK Shared Action Plan is one of the first steps for a care manager and family. To set these goals, the care manager will ask questions to help identify areas where the family would like support for their child. Families can ask for different kinds of support in order to meet these goals, including help scheduling appointments, connections to food resources, or help contacting a child’s school about support they need. Families can set up times to check-in and share resources with their care manager during a time that is best for them.
To date, care managers and families have completed 950 Shared Action Plans. In year two, NC InCK plans to engage and support more families. NC InCK is especially grateful to the teams of care managers at the Prepaid Health Plans, Community Care of North Carolina, Duke Health, and UNC Health for their support of children and families in the model.
Area 3: Focus Healthcare Investments
In January 2023, NC InCK, NC Medicaid, and the state’s Prepaid Health Plans launched NC InCK’s new Alternative Payment Model (APM). The APM supports high-quality health care for children and the medical providers who deliver these services. NC InCK’s APM encourages food and housing insecurity screening and allows primary care providers to promote Kindergarten Readiness. NC InCK also launched a webpage for primary care practices explaining the details of the APM.
Our Partners are Critical to Realizing NC InCK’s Vision
We are fortunate to have collaboration and support from a broad range of partners who make it possible to continue strengthening our model. We are particularly grateful to the partners with embedded NC InCK Integration Consultants. Having staff working as part of these institutions helps us better collaborate, navigate transitions in care for children, and access services and supports across NC InCK’s core child service areas. Thank you to the following entities who house NC InCK Integration Consultants within their teams and contribute to the cross-sector, collaborative design of our NC InCK model:
- Alliance Health
- Durham Families and Communities Rising
- Orange County Health Department
- Orange County DSS
- Granville Vance Health Department
- Division of Juvenile Justice and Delinquency Prevention
- NC’s five Prepaid Health Plans (PHP)
- Community Care of North Carolina (CCNC)
- Duke Health
- UNC Health
- Vaya Health
Looking Ahead: Strengthening Family Engagement in the NC InCK Model
NC InCK care managers call families to give them the option to participate in our service model. In year two, we aim to increase the number of families who receive these calls and accept care management services. Care managers engaged approximately 30% of the families we outreached in our first year. To strengthen outreach and engagement, NC InCK is piloting several different approaches in 2023, including:
- Accepting NC InCK referrals from school nurses, juvenile justice court counselors, and care managers in health systems
- Housing NC InCK care managers in one large primary care clinic (Burlington Pediatrics) to meet families and build in-person connections
- Building a series of toolkits and materials for using texting and alternative communication approaches to more effectively reach families
In 2023, we plan to highlight the promising approaches, systems gaps, and learning areas from our model through regular updates like this. Stay tuned for future updates on our in-depth work to connect more children in foster care with care management services, our goals and early implementation lessons from the NC InCK Alternative Payment Model, and our strategies across service areas like food and early childhood.