Although NC InCK is a pediatric model, data on care management can provide valuable lessons relevant to any entity aiming to improve population health.
This October, Eleanor Wertman, NC InCK Care Integration Director, shared insights about implementing care management at the National Association of Accountable Care Organizations (NAACOS) Fall Conference. About 700 attendees discussed how to improve population health and health care quality. Stephanie Turner of UNC Health Alliance and Tara Kinard of the Duke Population Health Management Office co-presented NC InCK’s data with Wertman in a session titled “Shaping Future Health: Upstream Care Management Strategies for High-Needs Populations.”
Wertman’s portion of the session focused on how the NC InCK model aims to set children and families up for long-term well-being and how it differs from traditional care management approaches. Here, Wertman discussed NC InCK’s prioritization of families for care management who are at high or rising risk of poor health and how their risk stratification algorithm uses nonclinical data to identify families with high rates of unmet social needs that threaten children’s health. This approach allows care managers to reach rising-risk families earlier and mitigate negative health outcomes.
The presentation also covered how family-centered care management has benefitted entire households, not just the children originally identified for engagement. Over the last few months, NC InCK has conducted qualitative interviews with families to better understand how care management can improve children’s health. Interviewees emphasized the importance of nonjudgmental and meaningful support; intensive, longitudinal assistance; and connections to essential resources. Families repeatedly noted the program’s positive impact on their children and, in turn, their households’ overall well-being. NC InCK Family Navigators helped caregivers be more present and available for their children by alleviating administrative burdens, financial strain, and health stressors.
Historically, many population health initiatives and value-based care contracts have focused on high-cost, high-need adults. However, NC InCK’s experiences demonstrate the importance and impact of reaching children before they develop chronic conditions or other health challenges. Engaging with children early in their lives can help them thrive in the long term and deliver immediate health improvements for their entire family, including adults. NC InCK was honored to share this important work and advocate for the importance of child and family-focused approaches to population health!
Author:
Eleanor Wertman, MPH is the Care Integration Director for NC Integrated Care for Kids, where she co-leads implementation of the care management model and leads the program’s Alternative Payment Model. Eleanor has a background in helping health care systems design and launch programs that address patients’ nonclinical barriers to health and well-being. Prior to joining InCK, she worked on health care quality improvement initiatives, built and led a community health worker team at UNC, and led a mobile COVID vaccination unit. She holds a Master of Public Health from UNC Gillings School of Global Public Health and a BA in History from Yale University.