This quick guide explains Medicaid care management, how it can help families, and key resources for how families can access services.
Family Navigators – Care Managers
Autism Spectrum Disorder (ASD) Integrated Care Rounds (May and June 2025)
Description
NC InCK's May and June 2025 Integrated Care Rounds discuss autism spectrum disorder (ASD) through a trauma-informed, strengths-based lens. These sessions share practical resources and insights that offer a deeper understanding of how we can best support individuals with ASD and their families.
Key Takeaways
- Autism spectrum disorder (ASD) presents with varying degrees of severity and may require different levels of support. If developmental concerns are present, getting evaluated can be critical to accessing services and supports.
- Evaluation referrals can be made by the individual’s pediatrician, primary care provider, or school for students in grades K-12. Due to the volume of referrals, individuals are encouraged to get on several wait lists and to follow up often on any cancellations or no-shows.
- While waiting for an evaluation, learning more about autism spectrum disorder is encouraged, as it can provide helpful context and informed decision-making. It may also be helpful to practice coping skills while not in a state of crisis to reduce the inability to access them during times of stress.
- Getting connected to therapies- such as outpatient behavioral health, speech/occupational/physical, or music/art/equine- could also be beneficial while waiting to be evaluated.
- Most individuals with an autism spectrum diagnosis will be eligible for tailored care management provided by the MCO specific to their county.
Resources
- Autism Society of NC (ASNC) - Aims to improve the lives of individuals with autism, their families, and communities through advocacy, education and direct services. ASNC offers a directory of resources for evaluations, support groups, training, and advocates for policies that support the needs of individuals with ASD.
- Children’s Developmental Services Agency (CDSA) - Provides early intervention supports and services for families and their children ages 0-3 with special needs in the form of assessments and evaluations, service coordination, and transition planning.
- Exceptional Children’s Assistance Center (ECAC) - Provides information, support, training, and resources to assist families caring for individuals with special needs from birth to age 26.
Interpersonal Violence (IPV) Integrated Care Rounds (April 2025)
Description
NC InCK's April 2025 Integrated Care Rounds discuss interpersonal violence (IPV) and resources that can help strengthen protective factors and reduce harm.
Click this link for the April 2025 Interpersonal Violence Slide Deck
Key Takeaways
- Interpersonal violence is widespread and has great financial and psychological impacts on survivors. The daily work care managers do with families, such as connecting to economic, behavioral health care, and parenting supports, increases protective factors and reduces harm from IPV.
- Understanding the warning signs and stages of abuse can help care managers screen and talk with clients about IPV. Best practices for screening include asking in private, providing multiple opportunities for disclosure, and being prepared to offer resources and safety planning when discussing IPV. A variety of assessment and safety plan tools are available in the slide deck.
- When talking with someone about IPV, it is important to be empathetic and non-judgmental in your approach. It is important not to pressure individuals to share information or take steps they are not ready for. Instead, they should be offered options for support and given space to make decisions when ready.
Resources
- Durham Crisis Response Center (DCRC): DCRC works to end domestic, sexual, and family violence, and human trafficking in Durham County, NC through advocacy, education, support, and prevention.
- Friend to Friend: Friend to Friend is a non-profit organization in Moore County, NC dedicated to helping survivors of domestic violence, sexual assault, and human trafficking.
- National Domestic Violence Hotline: Call 1-800-799-7233 or text “START” to 88788 for 24/7 support. Explore the website for resources to help identify abuse, plan for safety, and support others.
- North Carolina Coalition Against Domestic Violence (NCCADV): NCCADV provides a searchable database of local domestic violence agencies in all 100 counties across North Carolina. They offer supports that include 24-hour confidential crisis hotlines, emergency shelter, support groups, and counseling.
- NC InCK Interpersonal Violence Resources: This document includes interpersonal violence support resources for Durham, Orange, Alamance, Granville, and Vance counties in NC as well as national, statewide, and surrounding county resources.
Family Engagement Research Part 2 Integrated Care Rounds (February 2025)
Description
Check out NC InCK's February 2025 Integrated Care Rounds where we dive into findings from our conversations with families engaged with the NC InCK care model.
Click this link for the February 2025 Family Engagement Research Part 2 Slide Deck
Key Takeaways
- Families who chose not to participate in NC InCK care management expressed skepticism about the usefulness, legitimacy, and/or confidentiality of care management.
- Many of these families were unfamiliar with care management and made assumptions based on prior negative experiences with the healthcare system or other social services.
- Families who initially participated but then were lost to follow up often talked about competing priorities (work, childcare, life events, health challenges) that made it hard to keep up with regular scheduled care management phone calls during business hours. Texting was helpful to keep busy families connected.
- Others felt they hadn’t received services they expected to receive, like financial or housing assistance, because resources weren’t available or there were long wait lists
- Many families in both groups were interested in being reconnected to the program, either because they felt they had a better understanding of care management or because their needs had changed since the initial outreach.
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.
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)
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
Serving Families with Mixed Immigration Statuses Integrated Care Rounds (April 2024)
Description
This month, the NC InCK team discusses resources available to children and families with mixed immigration statuses and how to access local supports.
Click this link for the April 2024 Serving Families with Mixed Immigration Statuses Integrated Care Rounds Slide Deck
Key Takeaways
- About 1 in 5 children in NC have a parent who is an immigrant. Many children in NC InCK have caregivers and other relatives in their household who have an immigration status different from their own. These differing statuses affect families’ eligibility for important resources.
- Understanding and discussing families’ immigration status can be confusing and intimidating. Building trust and knowing the right questions to ask can help!
- Citizen children of immigrant parents qualify for services like SNAP and Medicaid regardless of their caregivers’ immigration status. While many government programs require certain legal statuses to participate, programs like community food banks, free/reduced price school meals (and summer meals/Summer EBT), and WIC are open to all regardless of status.
Resources
- Multilingual Public Charge factsheets from NC Justice Center to help families understand that accessing benefits like SNAP for their children will not endanger their path to citizenship/their immigration status
- Bull City Futsal Academy, Durham-based nonprofit offering free in-school and community-based soccer & futsal programs with a focus on serving BIPOC youth.
- HRSA Directory of Federally Qualified Health Centers and NC Association of Free & Charitable Clinics Directory to find free/reduced-price health care services for uninsured and/or undocumented family members
Early Childhood Part 2 Integrated Care Rounds (March 2024)
Description
In this second discussion of early childhood supports, the NC InCK team outlines services, collaboratives, and resources that help early care, education, and health.
Click this link for the March 2024 Early Childhood Part 2 Integrated Care Rounds Slide Deck
Key Takeaways
- Child Care Referral Central is a regional (Alamance, Caswell, Person, Franklin, Granville and Vance counties) collaborative that offers free customized childcare referrals & information on vouchers or scholarships for all families seeking care from birth to age 12.
- Early Intervention services are critical in supporting children and families. Two major programs that provide these services are: the Children’s Developmental Services Agency (CDSA, aka Infant-Toddler Program) and Care Management for At-Risk Children (CMARC). CDSA offers services for kids ages 0-3 who exhibit developmental delays or have established conditions, while CMARC supports children who have special healthcare needs, ACES, exposure to substance use, or been in the neonatal intensive care unit.
- To apply for Pre-K, children must live within the district they are applying for, and be aged 4 (or will turn 4) by August 31st. Pre-K application materials vary by county.
Resources
- Review the Child Care Referral Central online referral system and contact information.
- Visit this website to learn more about CDSA services and find your local CDSA.
- Current list of local Pre-K contacts who can provide information on the enrollment process and available programs.
- A list of Smart Start partners in Durham County who can provide resources across early care and education, health, and family support.
- Be familiar with milestone goals for each age group: CDC’s Developmental Milestones | CDC
Supporting Children and Families’ Physical Health Integrated Care Rounds (February 2023)
Description
The NC InCK team discusses important information about how our Family Navigators can support pediatric physical health.
Click this link for the February 2023 Supporting Children and Families' Physical Health Integrated Care Rounds Slide Deck
Key Takeaways
- Family Navigators (FNs) are communicators: How to start the conversation on challenging topics: for example, when discussing obesity, avoid using words like fat, obese and BMI. It takes time to establish trust. Don’t be afraid to put sensitive topics in a “parking lot” for a future call.
- FNs are educators and advocates: Food security directly impacts physical health along with so many other parts of life. Working with members and ensuring they are linked with SNAP/WIC and the VAB each PHP offers are critical steps to helping members stay physically healthy.
- FNs are knowledgeable: Physical health is important all year around. During the summer months there are a variety of high-quality summer opportunities to stay informed about and connect families to including camps with scholarship supports, and summer jobs & internships for adolescent and young adult members.
Resources
- WOW Coalition – Information for Granville and Vance counties with tips on healthy eating, wellness at the workplace, and ways to get physically active in the community.
- More In My Basket – An organization that can help North Carolina families connect to Food and Nutrition Services.
- Amerihealth Benefits , CCH Benefits , Healthy Blue Benefits , United Benefits , Wellcare Benefits – Value added benefits by each PHP can assist with resource needs for families (food, clubs, etc)