This is a data companion for health care clinics to learn more about NC InCK's Shared Action Plan.
Author: manda.hufstedler@duke.edu
November 2024 NC InCKlings Newsletter
In the November 2024 edition of the NC InCKlings newsletter, you'll find updates, insights, and opportunities to engage with NC InCK. Topics include:
- Opportunities to Engage with NC InCK
- NC InCK Care Model Updates
- Family Navigator Capacity Building
- Staying Connected
To receive future updates, you can email info@ncinck.org to join our mailing list.
The November 2024 NC InCKlings is available at this link.
NC InCK Youth Council Voices: Layla B.
Meet Layla, a high school junior who is a passionate student and a committed NC InCK Youth Council member. At school, she is actively involved in the Art Club, Student Government, and Debate Club. Additionally, she is a dedicated member of the National FFA Organization, National Honor Society, and Girl Scouts, where she engages in numerous community projects. With three years of experience on the NC InCK Youth Council, Layla joined to connect with like-minded peers who share her dedication to positive change. Most of all, she believes in amplifying the often-overlooked voices of adolescents and young adults. Hear more from Layla below.
Responses have been edited for clarity and readability.
Layla B., NC InCK Youth Council member
How has the Youth Council encouraged you to collaborate with other young people to better understand their experiences?
Layla: Being a NC InCK Youth Council member encouraged me to come out of my shell and start conversations with new people. During meetings, I feel comfortable exchanging ideas with other like-minded students and hearing about their own experiences and opinions.
How have monthly Youth Council meetings impacted your understanding of child and family-led community programs and partners?
Layla: Through Youth Council meetings, I have become more informed about things like community programs that I would not have learned otherwise. Increased awareness about these resources has allowed me to fully appreciate their impact.
How does the Youth Council help NC InCK incorporate the adolescent and youth-adult experience into their decision making?
Layla: The Youth Council does everything in its power to include the voices of the adolescents and youth who will be engaged in the NC InCK model. It is important that we include the opinions and experiences of those who are actually dealing with the problems we hope to solve. Without this perspective, it is impossible to know what will truly help these individuals. Everyone’s voice needs to be heard.
Supporting Children & Youth with Special Health Care Needs Integrated Care Rounds (September 2024)
Description
Join the NC InCK team as they discuss how best to support children and youth with special health care needs in the September 2024 Integrated Care Rounds.
Click this link for the September 2024 Supporting Children &Youth with Special Health Care Needs Integrated Care Rounds Slide Deck
Key Takeaways
- Children with a medical complexity make up less than 1% of children in the U.S.
- A care coordination team can support families by understanding concerns, navigating financial or housing issues, advocating within the public school system, and guiding ongoing goals of care as well as discussions about realistic goal setting
- The CAP/C Waiver provides additional supportive services to supplement services from regular Medicaid Direct/insurance such as private duty nursing, durable medical equipment and supplies, therapy services, and home health
Resources
- NC InCK Children and Youth with Special Health Care Needs Guide: This guide is designed for Family Navigators and other professionals serving families of children with complex medical needs, intellectual disabilities, and/or traumatic brain injuries. This guide contains information to help Family Navigators and others connect CYSHCN to the services/supports they need to thrive.
- North Carolina LIFTSS: NC Medicaid implemented NCLIFTSS (Linking Individuals & Families to Long Term Services and Supports). NCLIFTSS provides Medicaid beneficiaries a long-requested single point of entry for accessing Medicaid Lomg Term Services and Supports and streamline processes between initial contact and service provision.
- NC Exceptional Children's Assistance Center: A parent organization, committed to improving the lives and education of ALL children through a special emphasis on children with disabilities and special healthcare needs. See the website for important resources, trainings, and opportunities to connect with a parent educator.
Quick Reference Guide: Connecting Families to Economic Supports
Use this quick reference guide to help reduce families financial strain.
Looking Back and Moving Forward: Judy Lawrence, Integration Consultant, Reflects on NC InCK and Juvenile Justice-Involved Youth Initiatives
I have served as an Integration Consultant for NC InCK, based out of the NC Division of Juvenile Justice and Delinquency Prevention (DJJDP), since November 1, 2021. As I prepare to move on from this work, I have been reflecting on the impact NC InCK has made on juvenile justice-involved youth, families, and communities.
One goal of all InCK programs is to holistically assess and address ways to prevent out-of-home placements of youth. This certainly applies to youth involved with the Juvenile Justice system and why it is a focus for NC InCK.
Through policy studies, workgroup efforts, and intern research, our NC InCK team has found multiple areas of potential influence for these vulnerable youth.
1. Medicaid Suspension and Reinstatement
When a youth is committed to a Youth Development Center (YDC), their Medicaid is suspended until no more than 24 hours pre-release. However, the current process for reinstatement after release is completely manual which often leads to a gap in Medicaid coverage. In collaboration with our NC Medicaid team, we concluded an automatic reinstatement process would help solve this problem. Through further research, we learned of the opportunity to change the pre-release timeframe for reinstatement of coverage. Our workgroup developed talking points, shared resources, and educated DJJDP and Medicaid staff on how the current policy has had a negative impact on youth in need of pre-release services, specifically for mental and/or behavioral health.
2. Resources for Adolescents and Young Adults, Focusing on Juvenile Justice Involvement
Not all care managers are trained to work with adolescents and young adults or aware of the complex needs of this population. To support care managers, we created an extensive, though not exhaustive, guide of resources and supports for adolescents and young adults involved with the Juvenile Justice system and the NC InCK care model. This guide includes information about physical, behavioral, mental, and sexual health as well as education, employment, finances, housing, nutrition, and support. It also shares ideas and tips for care managers to discuss goals and the transition from adolescence to adulthood with the youth and/or family.
3. Juvenile Court Counselor (JCC) Community Referrals
When Medicaid launched Tailored Care Management (TCM) in December 2022, the landscape of Juvenile Justice and Medicaid changed significantly. Most juvenile justice involved youth transitioned to TCM, making them ineligible for NC InCK care management. However, NC InCK saw an opportunity to engage more youth in the model earlier and began training Juvenile Court Counselors (JCCs) on how to make direct referrals for NC InCK care management. These training sessions began in May 2023 and have resulted in nearly 40 referrals so far. Though some of those referred were TCM-eligible, several decided to receive support from NC InCK Family Navigators. Juvenile Court Counselors have expressed their support and positive experience with the direct referral process.
4. Connecting with Juvenile Justice Behavioral Health (JJBH) Partnerships
Each NC InCK county has an established Juvenile Justice Behavioral Health (JJBH) partnership intended to address mental health and substance use needs of youth and families involved with DJJDP. We connected with the Alliance JJBH team on July 17, 2023, and continue to participate in meetings regularly. Through this, we created a process for JJBH partners to refer youth to NC InCK care management leveraging the existing referral path for JCCs. We hope to continue to expand these efforts through additional partnerships in the coming months.
Moving Forward: Hope for Improved Medicaid Coverage and Services
I am confident that NC InCK and DJJDP will continue to build on these achievements, furthering their commitment to provide appropriate services for supporting Juvenile Justice-involved youth. It is my hope that Medicaid will make federal policy changes to allow all vulnerable youth uninterrupted access to Medicaid services while in YDC commitment. It is my dream that, by providing holistic, equal, comprehensive Medicaid services to youth, North Carolina will see a reduction in juvenile crime and delinquency, youth with intellectual or developmental disabilities (I/DD) and behavioral health needs will not be subjected to the juvenile justice system, and families will prosper as they receive the care and services they need to thrive.
I am deeply grateful for the opportunity to work with NC InCK and DJJDP and will carry my experience in my heart always. May we all keep up the InCKredible work!
Author:
Judy Lawrence: has been innovative and inspiring in her role with DJJDP and NC InCK since November 2021. Her work with Chief Court Counselors and staff has ensured that the needs of youth are addressed by collaborative communications across child and family-serving agencies. Ms. Lawrence’s leadership within the NC InCK structure, and her leadership to connect and strengthen a collaboration between DJJDP and NC Division of Health Benefits to respond to the CMS Section 1115 Waiver which, among other benefits, will enable Medicaid funds to be utilized by youth during the end of their stay in YDCs.
Ms. Lawrence has worked with the State of North Carolina since February 2007, holding leadership roles with NC DHHS, the Administrative Office of the Courts, and DJJDP. She has led several projects for TANF and SNAP programs, administered a District Guardian ad Litem program, and managed the national Work Support Strategies and SNAP Collaborative initiatives. She has most recently transitioned to the position of Medicaid Senior Program Manager for NC Advanced Medical Home. Prior to her work with North Carolina government systems, Ms. Lawrence was a Social Work Supervisor with the Alamance County Department of Social Services in North Carolina, and worked with social services agencies in West Virginia, Florida, and Ohio.
Ms. Lawrence earned her Bachelor of Science degree in Family Studies and Human Services from Ohio University in 1998 and achieved her Lean Process Improvement certification from NC State University in 2017. In her non-work life, she enjoys reading, swimming, baking, and spending time with her handsome hubby and kittos.
Family Experiences with Care Management Integrated Care Rounds (August 2024)
Description
In the August 2024 Integrated Care Rounds, the NC InCK team discusses family experiences engaging in the NC InCK care management model. We also learned about the positive outcomes that have resulted from care management.
Click this link for the August 2024 Family Experiences with Care Management Integrated Care Rounds Slide Deck
Key Takeaways
Families who are engaged in or graduated from NC InCK care management reported many positive outcomes from program participation, particularly:
- Reduced caregiver stress due to improved economic stability and assistance with connecting to and coordinating various supports for their children (and themselves!)
- Improved health outcomes for children due to connection to essential health care services and food and nutrition supports
- Improved overall family well-being due to reduced administrative burden on caregivers and improved whole-family access to a broad spectrum of services and supports (from after-school programs and school supplies to vision care to over-the-counter cold medications)
Promoting Kindergarten Readiness in Pediatric Primary Care Practices Using a Multi-Center, Longitudinal, Learning Collaborative Model
Only half of children are fully ready for kindergarten, and only 42% of 3- and 4-year-olds are enrolled in preschool in North Carolina. However, early childhood well visits can support optimal health and well-being and connect children to the community services they need to become kindergarten-ready.
In 2023, North Carolina Integrated Care for Kids (NC InCK) launched the Kindergarten Readiness Promotion Bundle (KRPB), a novel quality metric of their Alternative Payment Model (APM). The NC InCK APM includes financial incentives for providing and reporting on clinical services and community referral activities that support kindergarten readiness. The measure components include developmental screening, social-emotional screening, fluoride varnish application, and literacy promotion.
To educate practices and improve the delivery of the KRPB components, NC InCK launched a 9-month Kindergarten Readiness Learning Collaborative (July 2023 – March 2024) consisting of quality improvement (QI) support, data feedback, and monthly topic-focused webinars across three clinically integrated networks (CIN) in North Carolina.
The Learning Collaborative aimed to increase the percentage of children (from birth to age 6) receiving the KRPB during well visits from 0% to 60%. Collaborative leaders shared best practices along with relevant QI tools to help practices test and assess the impact of process changes. In turn, practices completed baseline and end line surveys and submitted monthly data on how they were using the KRPB code and its components. Providers earned American Board of Pediatrics (ABP) Maintenance of Certification (MOC) Part 4 credit and AMA PRA Category 1™ Performance Improvement Continuing Medical Education (PI CME) credits for participating in three or more Learning Collaborative webinars.
Each Learning Collaborative session focused on a different component of the KRPB:
July: Kickoff and Overview of Kindergarten Readiness Promotion Bundle
August: Connecting to Pre-K
September: Literacy Promotion
October: Parenting Program Referrals and Social/Emotional/Behavioral Screening and Follow-Up
November: Integrating Multiple Screenings to Address Early Childhood Mental Health
December: Sustaining Change and Exploring New Partnerships
January: Supporting Oral Health
Overall, 15 practices from across three health systems participated in the Learning Collaborative. Practices used various strategies, including building partnerships with community-based resources and standardizing clinic workflows for referrals to improve their KRPB participation. Future work is still needed to study the sustainability of these efforts and determine the impact of primary care-based kindergarten readiness efforts.
Author:
Sara Bryk, MPH: graduated in 2024 from the University of North Carolina (UNC) at Chapel Hill with a Master of Public Health degree and a concentration in Maternal, Child, and Family Health. She also received a Certificate in Improvement and Implementation Science and was awarded the Foreign Language and Area Studies Fellowship for Portuguese and Latin American studies. While at UNC, Bryk served as a graduate research assistant at the World Health Organization Collaborating Center for Research Evidence for Sexual and Reproductive Health, and as a project manager on the Kindergarten Readiness Learning Collaborative at NC InCK. Prior to graduate school, Bryk spent three years as a research analyst at Mathematica, where she provided mixed-methods research and project management support for quasi-experimental evaluations of international development projects. She also spent a year as a Fulbright Teaching Fellow in Colombia and holds a B.A. in human biology and sociology from Scripps College.
NC InCK Team Collaborates with North Carolina Area Health Education Centers (NC AHEC) on Statewide Community Health Worker Training Module
Throughout 2023, members of the NC InCK Team collaborated with the Mountain Area Health Education Center (MAHEC) to create a training module that educates on supporting children’s unique needs in a family-centered way. NC InCK’s participation in this NC AHEC training series (which is available for free statewide) was an exciting opportunity to share our expertise on child and family health beyond NC InCK’s five Medicaid counties (Alamance, Durham, Granville, Orange, and Vance).
Registration Page for NC InCK’s Newly Released NC AHEC CHW Specialty Training Program Module.
Beyond introducing the audience to NC InCK, the training focused on two areas that are both challenging to navigate and fundamental to pediatric health: food security and early childhood development and education. The training is intended to educate community health workers and other family-serving professionals across North Carolina about:
- The importance of food security to children’s long-term health and well-being
- Critical resources that promote food security and ensure access to early intervention services and high-quality early childhood education programs
- The importance of high-quality, developmentally appropriate early childhood education to children’s long-term health and well-being
- Best practices in helping families navigate application and enrollment processes for federal nutrition programs, early intervention screening programs, and childcare/early childhood education services
If you are interested in learning more or taking the training for yourself find the course catalogue here or register at this link.
Authors:
Eleanor Wertman, MPH: Eleanor is the Care Integration Director for North Carolina Integrated Care for Kids (NC InCK). She holds an MPH from UNC Gillings School of Public Health and has a background in healthcare quality improvement and value-based care. Before joining the InCK team, Eleanor worked for UNC Population Health, where she developed programs to address UNC patients’ nonclinical barriers to health and implement systemwide social drivers of health screening. She now leads the implementation of the NC InCK care management model and the NC InCK alternative payment model.
Josie Hatley, MPH: Josie is the Associate Director for Strategy and Operations for NC InCK. Josie holds an MPH in Maternal, Child, and Family Health, along with a Certificate in Innovation for the Public Good from UNC Gillings School of Global Public Health. Josie works to understand the systems that impact children during early childhood within the context of the families, caregivers, and communities around them.
Supporting LGBTQIA2S+ Youth and Young Adults Integrated Care Rounds (May 2024)
Description
The May 2024 Integrated Care Rounds discusses supporting LGBTQIA2S+ youth in the NC InCK model. The NC InCK team and guests discuss health disparities, terminology, policy considerations, supportive services and resources, and the importance of affirming care.
Click this link for the May 2024 Supporting LGBTQIA2S+ Integrated Care Rounds Slide Deck
Key Takeaways
- LGBTQIA2S+ individuals are more likely to experience certain health disparities due to stigma and discrimination they experience in the healthcare setting and their daily lives.
- In efforts to provide compassionate and effective care, it is essential to recognize key components of being an active ally. Learning about terminology, pronouns, and language considerations is an important step in supporting LGBTQIA2S+ youth. Transgender and nonbinary youth who said their pronouns were respected most or all of the time attempted suicide at half the rate of those whose pronouns were not respected.
- Gender-affirming care is life-saving healthcare for LGBTQIA2S+ individuals of all ages. Therefore, it is important to have awareness of policy impacts on access to care, how to identify affirming providers, and how to navigate support with parents and caregivers.
Resources
- The Trevor Project – The Trevor Project is a non-profit suicide prevention organization that provides 24/7 crisis support services, research, and advocacy for LGBTQIA2S+ young people. Find information on getting help as well as resources and guides in their resource center.
- Tavi Hawn, LCSW-C – Website for Tavi Hawn, speaker, author, consultant, and therapist. Links to books authored by Tavi Hawn: The Gender Identity Guide for Parents: Compassionate Advice to Help your Child be their Most Authentic Self and Cultural Awareness in Therapy with Trans and Gender Non-Conforming Adults and Older People: A Practical Guide.
- Campaign for Southern Equality – Find information on research and policy, Southern Trans Youth Emergency Project (STYEP), legal resources, and more.
- Human Rights Campaign – Find resources on legislation, healthcare rights, and tools for equality and inclusion.
- OutCare – LGBTQIA2S+ affirming provider search directory and health resources