This is a data companion for health care clinics that shares information about the NC InCK Alternative Payment Model.
Author: manda.hufstedler@duke.edu
Guide for Engaging Adolescents in the Care Management Process
This guide for Family Navigators shares information for engaging adolescents in the care management process.
NC InCK Featured on Public Health Informatics Institute
The Public Health Informatics Institute (PHII) website recently highlighted NC InCK’s efforts in promoting collaboration between core child service areas.
The article underscores NC InCK’s focus on supporting children and families through Family Navigators and the use of cross-sectional data. Additionally, PHII’s feature outlines the implementation of the NC InCK alternative payment model and dedication to sustaining our innovative framework of integrated care throughout North Carolina.
NC InCK Welcomes New Executive Director Rushina Cholera
NC InCK is excited to welcome Dr. Rushina Cholera as the model’s new Executive Director effective July 15. Rushina succeeds NC InCK’s founding Executive Director Charlene Wong, who transitioned to her new role as Strategic Advisor with the Centers for Disease Control and Prevention (CDC) this summer. This opportunity will allow Charlene to take lessons learned from NC InCK and apply them to families nationwide. Rushina was formally introduced to the NC InCK community and partners at our July 28 webinar, where she took the opportunity to share her hope that the model continues to build on its strong foundation of success. She named enhancing NC InCK’s focus on equity as one of her initial priorities for the model, saying:
"Our NC InCK team has so many strengths. I hope I can bring an additional focus to how we think about equity. All of us came to this work because of an interest in social justice, and we can do even more in centering equity at NC InCK."
Rushina with her husband and children Kian and Nico
For the last two years, Rushina served as a member of the NC InCK Executive Team as Research and Evaluation Director. In this previous role with NC InCK, Rushina supported the model's efforts to leverage data and perspectives learned from families and care managers in order to better design our approach to improving NC InCK services. Rushina has also supported NC InCK by mentoring students and summer interns focused on areas including nutrition and food insecurity, family engagement, and risk stratification.
Dr. Mike Steiner, NC InCK Health Director, said of Rushina, “I have known Dr. Cholera for almost ten years. She is incredibly thoughtful, insightful, caring, driven, and brilliant! She will be a great leader for this next phase of NC InCK.”
In addition to her role with NC InCK, Rushina is a practicing pediatrician in Durham County. She is also an Assistant Professor of Pediatrics and Population Health Sciences at the Duke School of Medicine, as well as a Faculty Fellow at the Duke Margolis Center for Health Policy.
Dr. Cholera completed both her MD and Ph.D. in Epidemiology at the University of North Carolina at Chapel Hill.
Sleep Hygiene Guide for Children and Families
This guide shares information and tips related to sleep hygiene. It includes check lists with healthy sleep habits, a bedtime routine plan template, resources, and example Shared Action Plan goals for care managers.
Food and Housing Measures Data Companion for Clinics
This data companion for health care clinics shares information on food and housing measures and the NC InCK Alternative Payment Model.
Education-Related Awareness Measures Data Companion for Clinics
This data companion for health care clinics shares information on education-related awareness measures and the NC InCK Alternative Payment Model.
NC InCK: Year One in Review
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.
NC InCK November 2024 Webinar Recording
The November 7, 2024 webinar shared highlights of the model, including a general overview of NC InCK's goals and strategies, information about NC InCK's Alternative Payment and Care Models, and updates about research questions NC InCK hopes to answer. Watch the November webinar below.
Concrete Economic Supports Part 2 Integrated Care Rounds (June 2023)
Description
The NC InCK team and our guests discussed economic hardship and its impact of children and families during the second part of the Concrete Economic Supports Integrated Care Rounds event (June 2023).
Click this link for the June 2023 Concrete Economic Supports Integrated Care Rounds slide deck.
Key Takeaways
- The 2023 NC Child Health Report Card found that 40% of children in North Carolina live in poor or low-income households. Poverty, the stress caused by the experience of poverty, and the interaction with multiple systems is linked with multiple poorer health and well-being outcomes.
- This training includes information on accessing supports, including clothing, internet, utilities, WorkFirst, and Unemployment benefits. Use these resources in addition to those shared in the March 2023 Integrated Care Rounds. Viewers will learn how to support families through understanding and applying for supports.
- Family Navigators should actively support families in connecting to and enrolling in economic supports through walking with them to complete forms, calling access lines, and following up on applications.
Resources
- WIC Referral Form: Complete the referral form to refer families to WIC as a nutrition support for families
- More in My Basket Referral Form: Can help families apply for SNAP; refer families today!
- Affordable Connectivity Program (ACP): Medicaid recipients are automatically eligible for the ACP internet subsidy (up to $30/month) and a discount (up to $9.25/month) on phone or internet service through the Lifeline program
- Unemployment Benefits: Find more information on what is needed to file for unemployment benefits