NC InCK supports the holistic health needs of Medicaid-eligible youth by facilitating the connection between families and care management services. Using administrative data from NC Medicaid, NC Department of Public Instruction, and NC’s Division of Juvenile Justice and Delinquency Prevention (DJJDP), NC InCK prioritizes children for care management services. However, that process has resulted in low engagement rates among eligible children and failed to identify all eligible children. The initial low engagement rates of the model are speculated to be caused by families’ lack of familiarity with NC InCK and the utilization of administrative data, with varying degrees of updates, which failed to identify eligible children promptly.

To improve data identification processes, increase engagement, and build trust in care management services, NC InCK implemented a community referral pathway to increase engagement and trust in care management services among NC InCK-eligible children. Last year, NC InCK began partnering with DJJDP and Alamance Burlington School System (ABSS) in NC InCK’s five counties -- Alamance, Durham, Granville, Orange, and Vance. Juvenile court counselors (JCCs) and school nurses may now complete a confidential survey that initiates a warm handoff of eligible children to NC InCK care managers (Family Navigators).

The NC InCK team worked with community partners to develop and implement the referral pathway. After development, the NC InCK research team gathered input from community partners on their experiences supporting NC InCK-eligible children. It worked to incorporate and tailor the proposed pathway for alignment. NC InCK then provided training to community partners on the new referral processes. Now, NC InCK regularly meets with partners in DJJDP and ABSS to track the program's efficacy and ensure we are meeting the needs and expectations of our partners.

The NC InCK team observed significant improvements in care management engagement rates and the identification of NC InCK-eligible children two months after the community referral pathway began. Families are hypothesized to have increased trust and rapport with their referrers, increasing their chances of engaging with NC InCK. Additionally, referrers have a working knowledge of the social needs of potential NC InCK-eligible children, which allows them to pinpoint children who would benefit from care management services. Community partners also expressed confidence in sustaining the referral process as a permanent facet of their workflows.