News

New NC InCK Research Shares Lessons from Families, Partners, and Whole-Child Data

Posted on by Josie Hatley

North Carolina Integrated Care for Kids (NC InCK) aims to share what we've learned with the broader community. Our recent publications—including work led by students and trainees—examine how families and partners experience the NC InCK model’s design and approach, how NC InCK identifies children who may benefit from extra support, and what it takes to finance whole-child care more broadly.

Start with the NC InCK foundations

An overview in Healthcare, "An introduction to North Carolina Integrated Care for Kids (NC InCK): A model to support whole-child health,” describes the design of the NC InCK model, including our approach to cross-sector risk stratification, family-centered care management, and an alternative payment model that includes measures of social needs and school readiness.

Families want flexibility

A qualitative study in Health Services Research, “Engaging Families in Pediatric Care Management,” examines caregiver participation in NC InCK. Research intern Hartlee Lidsky, MD, and our team found that clear messaging and simple eligibility criteria, plus care managers who can build relationships with caregivers from many backgrounds, all help with encouraging caregiver participation. Because families' needs and capacity change over time, flexible options are needed rather than a one-size-fits-all approach.

Foster care partners saw stronger connections

In “Cross-partner Perspectives on a Novel Approach to Care Management and Systems Coordination for Children in Foster Care” published in Academic Pediatrics, research intern Claire Sibold, MD, and NC InCK team members interviewed care management and social work professionals as well as caregivers of children placed in foster care who were receiving NC InCK care management. Stakeholders said the program linked parts of the foster care system that had previously operated in isolation, reducing the burden on individuals to navigate a complex and fragmented system.

Looking beyond healthcare data

In a new preprint, “Beyond Healthcare Utilization: A Whole-Child, Multi-Sector Approach to Pediatric Risk Stratification,” we describe how NC InCK combines health, education, social, and juvenile justice data to assign children to Service Integration Levels (SILs). Among about 99,600 Medicaid-enrolled children in our five-county region, roughly 5.5% were placed in Level 2 and 4% in Level 3. About one in five to one in four of these children had been rated low risk by their Medicaid managed care organization, suggesting that non-clinical factors help identify children who might otherwise be missed.

Paying for whole-child health

In “Advancing Financing Arrangements for Whole-Child Health: Challenges and Opportunities in Pediatric Value-Based Care” published in Pediatric Clinics of North America, NC InCK's Eleanor Wertman, MPH, and Rushina Cholera, MD, PhD, join Stephanie Ryan, MPH, and Charlene Wong, MD, MSHp, in examining what accountable care can mean for children. These researchers highlight evidence that accountable care can reduce hospital use and costs, while emphasizing that addressing social needs may require longer-term investment. They also identify Medicaid policy and contract design—including pediatric-specific quality measures, care management payments, social-needs supports, and data sharing—as key levers for progress.

NC InCK’s Summer 2025 Interns

Posted on by Lindsay Kenton

Throughout Summer 2025, the NC InCK team had the opportunity to collaborate with a group of phenomenal interns. Some of this past semester’s work included research to inform future local policy, an in-depth exploration of the Integration Consultant role, and reflections on system-level drivers of health inequities. Each intern brought a unique lens to NC InCK’s mission of building systems that support child and family health. Read on to learn more about their work, insights, and experiences. The NC InCK team is grateful for all of their work and the experiences we had along the way!

Claire Sibold_new

Claire Sibold is a fourth-year medical student at Duke applying to family medicine. She was drawn to NC InCK’s mission to build systems that holistically support children and their families and particularly valued the opportunity to conduct research evaluations that could influence local policy. At NC InCK, Claire interviewed care managers, integration consultants, social workers, and caregivers in the foster care system to understand their experiences with NC InCK care management. She appreciated having the opportunity to listen to these partners and let their experiences guide our understanding of the care management model’s impact. Claire’s favorite part of working with NC InCK is the team’s shared commitment to improving child health and well-being. Each member brings unique skills and experiences, which makes for a great learning environment! In her free time, Claire enjoys spending time with family and friends—preferably outdoors!

Eujin Chung_new

Eujin Chung, a sophomore at Duke, was drawn to NC InCK's mission of the reimagination of our healthcare system to prioritize child and family health. In particular, she is inspired by the way NC InCK roots its work in the community to be child- and family-led. Eujin found working on a project about the Integration Consultant role especially meaningful. “I learned what holistic care really means and how important it is to connect systems for children’s health,” she says. Her experience gave her valuable insight into care management and value-based healthcare—knowledge she hopes to use as a future physician.

Meera Nagara_new

Meera Nagara is a fourth-year medical student at UNC applying to pediatrics. Before medical school, she worked at a Federally Qualified Health Center in Wilmington, NC during the COVID-19 pandemic. There, she witnessed how her medical director collaborated with the community to improve early vaccine access. This experience revealed how system-level flaws—not just individual barriers—drive health inequities. Meera’s favorite part of working with NC InCK is the team's shared mission to improve health systems for children and families. She values the opportunity to grow alongside thoughtful and passionate colleagues who are committed to both innovation and equity. In her free time, Meera enjoys spending time with friends and is a former competitive jump roper!

Angiolina Llibre_new

Angiolina Llibre is studying pre-med and psychology at UNC. She’s a passionate advocate for Latino health equity and a valued contributor to NC InCK research. Her journey began through her work as a medical interpreter, where she met Dr. Rushina Cholera and discovered the power of using her bilingual skills to connect families, culture, and healthcare. Inspired by this experience, Angiolina joined NC InCK to continue championing health equity for Spanish-speaking communities. She’s found deep fulfillment in collaborating with a team that values diverse perspectives and thoughtful feedback. One of her biggest takeaways has been the importance of listening and incorporating input to strengthen her work. Outside of research, her favorite place is the Dominican Republic, where she enjoys swimming, snorkeling, and learning about coral reefs.

Daud Malik_new

Daud Malik is a second-year medical student at Duke with a deep interest in therapeutics. His work with NC InCK began through conversations with mentors at Margolis, who described it as a place where bold ideas are transformed into real systems of care. That promise of mentorship and impact drew him in—and delivered. One of Daud’s most meaningful projects involved analyzing 1115 Medicaid re-entry waivers to understand how states deliver care to justice-involved youth, building on his prior work registering halfway house residents for cancer screenings and primary care. At NC InCK, Daud has come to appreciate the power of humility in leadership, watching experts with decades of expertise in Medicaid, child health, and community care model openness and collaboration. As he pursues a future as a clinician-policymaker, he’s inspired by how frontline experiences with families can shape system-level change in community health.

Tami Hilton Retires After Decades of Service to North Carolina’s Children and Families

Posted on by Lindsay Kenton
Tami Hilton

After more than four decades of nursing and public health service, Tami Hilton—an Integration Consultant with North Carolina’s Integrated Care for Kids (NC InCK)—has retired. She is leaving behind a legacy of compassion, innovation, and unwavering dedication to children and families across the state.

Hilton began her career in 1982 as a nurse, serving in health departments, emergency rooms, and home care for children with complex medical needs. Her journey through public health eventually led her to Medicaid-managed care with United Healthcare and, most recently, to NC InCK, where she found a community of professionals equally committed to improving the lives of children.

At NC InCK, Hilton’s role was multifaceted. She mentored Family Navigators—nurses or social workers new to case management—helping them grow into confident advocates for children and families. “It’s so fun to watch someone blossom and be empowered to walk beside the families they’re serving,” she said. “They realize there’s no limit to how they can help lift the burden for families—whether it’s connecting a family to Make-A-Wish or helping a mom get a break.”

Creating Practical Resources for Family Navigators

A big part of Hilton’s recent work with NC InCK has involved creating practical resources for case managers that address everyday challenges such as sleep disruptions and sunscreen safety. “These aren’t things Medicaid usually pays for, but they’re things I care about—and they matter.”

Understanding how sleep disruptions uniquely affect families, Hilton developed a training initiative to equip Family Navigators with strategies for improving sleep routines. Whether helping a toddler sleep independently or supporting a newborn’s nighttime schedule, her work offered real relief to families. Colleagues often turned to Hilton for guidance on complex cases, including children in foster care who had experienced trauma and struggled with sleep. Though she didn’t consider herself an expert, Hilton embraced these opportunities to collaborate and offer compassionate, informed support.

Hilton has also championed awareness around sunscreen safety, especially for children. She raised concerns about common sunscreens containing hormone-disrupting ingredients and advocated for mineral-based options, particularly those with zinc. “I thought a lot of my sunscreens were good,” she explained, “but when I checked them on this great website that analyzes ingredients, I found some weren’t. It shows you which ones might cause skin allergies or contain hormone blockers.”

“You Can Become the Expert”

A pivotal moment in Hilton’s career came early on, when a child died from an asthma attack. “It changed me,” she said. “From that point on, I learned everything I could about asthma.” She was even named the North Carolina Asthma Champion in 2013 (a distinction from the Asthma Alliance of North Carolina) and the Smart Start of New Hanover County’s 2019 Children’s Champion. “It wasn’t about doing something new—it was about making sure people knew what was already out there.” Her story is a testament to the power of persistence, advocacy, empathy, and the belief that small changes can lead to lasting impact.

Hilton also emphasized the importance of NC InCK’s long-term case management model, especially for high-risk families. “A grandmother with mobility issues raising her grandkids needs consistent support—not just when the family is in crisis.” She praised the program’s success in partnering with child welfare agencies, easing the burden on social workers and improving outcomes for placement providers and guardians.

As NC InCK and the broader healthcare community bid farewell to Hilton’s daily presence, her influence will continue to ripple through the families she’s supported, the colleagues she’s mentored, and the systems she’s helped shape. In retirement, Hilton looks forward to focusing on movement and wellness—water aerobics, Pilates, and yes, pickleball. “That’s a requirement when you’re retired, I think,” she joked. “I’ve worked from home for decades, so I’m ready to move more and live healthier.”

Meet Kirsten Alfaro, Early Childhood Integration Consultant

Posted on by manda.hufstedler@duke.edu
Kirsten, age 4, at Head Start graduation
Kirsten, age 4, at Head Start graduation

Hi. I’m Kirsten (she/ella), and I’m the early childhood integration consultant (IC) at NC InCK. I provide trainings, resources, and hands-on support to care managers (CMs), who in turn, pour into the families we serve. CMs facilitate access for families, and our IC team has the unique opportunity to consider how we can build their capacity and knowledge in different child-serving sectors.

 

About Me

  • I was born in Yucatán, Mexico, and raised in Minnesota.
  • I’m a Head Start kid and the oldest of four siblings.
  • I was the first in my family to go to college, and my siblings followed.

These things have shaped how I walk through this world- they inform my work and fuel my passion to be a catalyst for change. I believe that every child deserves a safe home, nutritious food, and a caregiver who feels empowered, not overwhelmed. I also fundamentally believe in equitable access to healthcare and education. I’m sure most can agree both are important and complex systems, especially when they intersect, and even more so for historically marginalized families.

 

"Aren’t there programs and services designed to walk alongside families?”

Yes, and yet two of the biggest existing challenges we come across are that:

  1. Many families (and family advocates) aren’t aware of all the resources available to them.
  2. Those who are informed often face barrier after barrier—whether it’s fear, waitlists, turnover, funding, transportation, literacy, and more.

We often hear that “investing in a child is investing in the future,” but what does that really mean? What do we invest in, where, when, and for how long? Research says birth to age five are the most critical years in a person’s development. The first five years aren’t a phase—they’re the foundation on which we not only catalyze a successful academic career but also achieve better health outcomes1. However, our state and country are grappling with the effects2 of child-care deserts3, underfunded pre-K programs, and the expiration of federal pandemic-era stabilization funds. And while policymakers continue to debate solutions, children and families are often navigating fragmented systems alone.

I’m not saying I have the answer—but I said what I said. We’ve got work to do.

 

What I Do and Why It Matters

Building Capacity for Care Managers: ICs organize monthly Integrated Care Rounds (ICRs) with subject-matter experts based on the CMs’ needs. Alongside the ICRs, ICs create resources companions, author in-depth core child service area guides, and one-pagers for best practices on connecting families to specific supports. Part of our “secret sauce” is connecting families to various economic supports—even community events like Roll Up & Enroll or NC MedAssist—to help reduce out-of-pocket costs.

Navigating the Early Childhood Program:
When 2025–2026 applications opened for NC Pre-K, Early Head Start, and Head Start, I saw a chance to simplify a complex process. Because the programs differ across our five counties, I gathered key info—eligibility, links, and contacts—and created tools and trainings for NC InCK CMs supporting families with young children. My efforts meant that across our 23 CMs, more than 350 opportunities were created to effectively discuss early education and childcare with families with children ages 0-5. Investing in the development of our CMs not only impacts children currently enrolled in NC InCK, but extends to any family they work with.

When I joined NC InCK, I took on the Early Childhood Innovation Committee, a quarterly virtual space for early childhood leaders and advocates to share updates, network, and align on goals. I think there is so much room for creative collaboration, and I urge us all to be curious. Ask questions. Reach out. Celebrate each other. I don’t know how to fix fragmented institutions, but I think collectively, we can figure it out. Truthfully, sometimes I still wonder what leading the committee “should” look like, but I suppose it’s like most things: model the change you want to see.

 

References:

  1. CDC Archives. (n.d.). Archive.cdc.gov. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/policy/hi5/earlychildhoodeducation/index.html
  2. Crisis in childcare and the state of work in America. (n.d.). KPMG. https://kpmg.com/us/en/articles/2024/may-2024-childcare-crisis-state-work-america.html
  3. Strengthening Child Care in Rural North Carolina: Why Your Voice Matters | North Carolina Early Childhood Foundation. (2025, April 22). North Carolina Early Childhood Foundation. https://buildthefoundation.org/2025/04/strengthening-child-care-in-rural-north-carolina-why-your-voice-matters/
  4. Dukes, K. (2025, May). Child care programs consider closing following the end of stabilization grants. EdNC. https://www.ednc.org/05-01-2025-child-care-programs-consider-closing-after-stabilization-grants-end/

Author:

kirsten alfaro

Kirsten Alfaro serves as the Early Childhood Integration Consultant within Families and Communities Rising for the NC Integrated Care for Kids (NC InCK) Model. Kirsten holds a Bachelor’s Degree in Psychology and Linguistics with a Minor in Chicano-Latino Studies from the University of Minnesota. She has served as a Bilingual Family Advocate with Durham Children’s Initiative, a Youth Director with the YMCA, and a Sr. Outreach Coordinator—advocating for farmworkers’ access to healthcare.

May 2025 NC InCK Newsletter

Posted on by manda.hufstedler@duke.edu

In the May 2025 edition of the NC InCKlings newsletter, you'll find updates, insights, and opportunities to engage with NC InCK. Topics include:

  • Upcoming Events
  • NC InCK: 2024 in Review
  • NC InCK Research
  • Community Engagement Efforts

To receive future updates, you can email info@ncinck.org to join our mailing list.

The May 2025 NC InCKlings is available at this link.

Student Researchers Present NC InCK Care Management Findings at Academic Pediatric Association Region IV Conference 2024

Posted on by manda.hufstedler@duke.edu

NC InCK student researchers Claire Sibold and Hartlee Lidsky showcased their research on care management at the Academic Pediatric Association (APA) Region IV Conference. Their findings highlight the impact of NC InCK’s holistic and collaborative approach to care management.

Children identified for care management often experience complex medical, behavioral, and social challenges. Lidsky's work aimed to understand engagement with care management and identify important drivers of retention. This study revealed that while many caregivers were initially unfamiliar with care management, they valued the personalized support once they engaged.

Additionally, data showed that caregivers were more likely to stay engaged when communication is flexible, and care managers are compassionate and nonjudgmental. “A good care manager makes all the difference,” one caregiver noted. “I see her name and immediately feel relieved—she’s someone I can trust.”

Hartlee Lidsky presenting her findings titled, “Engaging Caregivers in Care Management: Mixed-Methods Lessons from NC InCK”
Hartlee Lidsky presenting her findings titled, “Engaging Caregivers in Care Management: Mixed-Methods Lessons from NC InCK”

Findings from Sibold’s work similarly emphasized the effectiveness of NC InCK’s care managers when working with children from the foster care system and highlighted the impact of NC InCK’s ability to bridge gaps between siloed systems.

Claire Sibold in front of her poster titled, “Evaluating North Carolina Integrated Care for Kids’ Novel Approach to Care Management for Children in Foster Care”
Claire Sibold in front of her poster titled, “Evaluating North Carolina Integrated Care for Kids’ Novel Approach to Care Management for Children in Foster Care”

A social worker interviewed for the study shared, “Care managers can sometimes get through red tape that we can't, and they have more resources to keep advocating for the child.” Another participant emphasized the value of deeper engagement, and the value of including everyone in the child’s life including teachers, coaches, even faith leaders, to support long-term growth.

NC InCK team and student researchers at the APA Region 4 Conference
NC InCK team and student researchers at the APA Region 4 Conference

With these insights, NC InCK continues to refine its approach and prove how comprehensive and collaborative care models can make a significant difference in the lives of children and families.

Biographies:

Claire Sibold is a third-year medical student at Duke University School of Medicine, originally from Massachusetts. She graduated from Davidson College in 2020 with a major in Biology and minor in Health and Human Values. Claire's research focuses on care management in foster care. She is passionate about implementing comprehensive systems of support for vulnerable patient populations. At Duke, she is in the Primary Care Leadership Track and plans to pursue a career in family medicine, where she can care for patients of all ages within her community.

Hartlee Lidsky, MPH, is a medical student at the UNC School of Medicine and graduate of the UNC Gillings School of Global Public Health. In July 2025, she will begin an Internal Medicine-Pediatrics residency at the University of Michigan. She is interested in health services research and Medicaid policy as mechanisms to improve care for historically underserved populations; and plans to pursue a career focused on care for socially and medically complex hospitalized patients.

NC InCK: 2024 in Review

Posted on by manda.hufstedler@duke.edu

The end of 2024 marks the third anniversary of NC InCK’s launch. Since 2022, the model has demonstrated the power of integrated care, serving roughly 3,000 children and families across five counties.

This year, NC InCK aimed to understand which model components have the greatest impact on child and family wellbeing and how these components can be improved and sustained in the future.

Feedback from families engaged in the NC InCK model
Feedback from families engaged in the NC InCK model

Area 1: Understand Needs

In 2024, NC InCK continued to use integrated data systems that combine information from Medicaid, schools, social services, and juvenile justice agencies to identify children who may benefit from care management and assign them one of three Service Integration Levels (SILs). Children in SILs 2 and 3 are prioritized for outreach by care managers. Each month of 2024, the SIL algorithm prioritized over 1,000 families for care management outreach.

A key focus this year has been understanding which children and families are being elevated for care management and which may be missed. One early finding from this work is that the algorithm may miss very young children who have fewer interactions with health and social systems, indicating that alternative pathways to engage this population may be necessary. Additional analyses will continue in 2025 to give NC InCK a clearer picture of the most important data in identifying children's unique challenges.

Area 2: Support and Bridge Services

This year, the model deepened its commitment to connecting families, especially those engaged through our care management program, to essential services. Our Integration Consultants (ICs) continued to provide individualized panel management support to frontline NC InCK care managers, ongoing group trainings and written resources to build care manager capacity. Highlights from this year’s IC capacity-building work included live trainings on topics like supporting LGBTQ+-identified youth and serving families with mixed immigration statuses as well as written resources like our quick guide to connecting families to economic resources and our new resource guide on serving children and youth with special health care needs.

Through our partnerships with the Alamance-Burlington school system and juvenile justice counselors, NC InCK has continued to test and refine referral pathways for trusted community partners to connect children and families to care management. NC InCK also worked to understand how these direct referral pathways complement the model’s algorithmic risk stratification strategy to engage children and families not originally elevated for, but who might benefit from, care management. Efforts in 2025 will focus on creating referral pathways with additional school systems and organizations serving children ages birth through five.

Additionally, NC InCK has worked closely with Community Care of North Carolina (CCNC) and local DSS offices across the NC InCK counties to strengthen connections to care management for children in foster care. At the end of 2024, about 95% of NC InCK-eligible children in foster care were enrolled in care management. In 2025, NC InCK will continue to build on this exciting engagement by piloting outreach to adoptive families and having NC InCK care managers join permanency planning review (PPR) meetings alongside other cross-sector care team members.

Area 3: Focus Healthcare Investments

In 2024, NC InCK clinics received data from their first year of participation in the Alternative Payment Model (APM), which links payments to meaningful health and social outcomes. Performance reporting gives clinics actionable insights into their achievements and outlines areas for growth. In 2025, the model will continue to foster APM participation across roughly 90 clinics by highlighting and disseminating lessons learned from high-performing clinics, refining documentation workflows for APM measures, and supporting quality improvement initiatives across sites.

Highlighting Family-Centered Care

Throughout 2024, NC InCK researchers interviewed families to understand their experiences with NC InCK care management. Interviewees included both Spanish and English-speaking families who 1) engaged in NC InCK care management, 2) initially engaged but were lost to contact, and 3) declined to engage in care management. These conversations revealed that engaged families benefitted from NC InCK care managers’ empathy, ongoing support in navigating complex systems, flexibility, and whole-family focus. Caregivers cited connection to essential clinical and nonclinical resources and reduced stress as major program benefits. One caregiver talked about the impact of NC InCK’s support on her children’s physical health: “My two sons were… borderline diabetics, and within four months, they went from borderline diabetes to no diabetes at all.”

Families also revealed barriers to engagement in care management, including insufficient community-based resources to meet needs like housing instability and competing demands on their time from work and family obligations. These findings reinforce the need for both programmatic flexibility to allow families to engage on their own terms as well as systems-level efforts to invest more resources in social support programs like rent assistance. Families also identified the need for clear, concise messaging about care management, its holistic scope, and its potential benefits to busy caregivers.

These stories illustrate the impact of family-centered care in developing resilience, confidence, and well-being among NC InCK families and highlight opportunities for ongoing program improvement and care manager capacity-building. Interviews will continue into the first few months of the new year and family-centered care will remain a priority as the model progresses in 2025.

Looking Ahead

Looking ahead to 2025, NC InCK aims to create an even more impactful and inclusive care model by continuing to update data integration strategies, strengthen direct referral pathways, develop new resources and supports for care managers, and share lessons learned with key partners to improve pediatric care management practices.

To learn more about how NC InCK is committed to creating more equitable care, join Integrated Care Rounds throughout the year and visit the Training, Resource, and Core Child Service Area web pages. Follow along as NC InCK strives to improve children’s health and well-being.

Authors:

website headshots_our team (5)

Ali Kilborn supports NC InCK as a Clinical Research Communications Specialist through the Duke Clinical Research Institute. As a communications specialist, Ali strives to promote health literacy by translating complex scientific information into easily understandable formats. Ali earned her Bachelor of Arts in Psychological and Brain Sciences focused on cognitive neuroscience at George Washington University and completed a post-graduate certificate in Pre-Medical Studies at Johns Hopkins University.

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Chelsea Swanson serves as an Assistant Research Director within the Duke-Margolis Institute for Health Policy, and as the Managing Director for the NC Integrated Care for Kids (NC InCK) Model. Chelsea holds a Master’s Degree in Public Health from the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill where she studied how systems and behaviors can drive equitable healthcare access.

Eleanor Wertman Care Integration Director

Eleanor Wertman is the Director of Care Integration 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 health care quality improvement and value-based care. Prior to joining the InCK team, Eleanor worked for UNC Population Health, where she developed programs to address UNC patients’ nonclinical barriers to health, including a Medicare transportation program and a community health worker team. She also supported system-wide implementation of social drivers of health screening at UNC Health. She now leads implementation of the NC InCK care management and alternative payment models.

NC InCK is Hiring a Senior Program Coordinator

Posted on by manda.hufstedler@duke.edu

NC InCK is looking for a Senior Program Coordinator who will help advance its mission of improving health outcomes for children and families.  

In this role, the Program Coordinator will organize events, including Partnership, Family, and Youth Council meetings, support operational needs, assist in development strategy, and collaborate with cross-sector partners. 

The ideal candidate will have experience creating and maintaining structures that support work across teams and competing priorities, have strategic planning and partnership development expertise, and be committed to advancing health equity and innovation.

Learn more and apply.  

NC InCK Youth Council Voices: Nasir N.

Posted on by manda.hufstedler@duke.edu

Meet Nasir, a high school senior and dedicated member of the NC InCK Youth Council. As the president of the East Investment Club, Nasir leads many initiatives, such as stock market games and competitions, to encourage financial responsibility among his peers. Outside of school, he is a dedicated pianist and composer, aspiring to create music for films, television, and video games. Additionally, Nasir is an active member of the National Achievers Society, where he helps plan cultural events at his school. With two years of experience on the NC InCK Youth Council, Nasir is focused on making lasting connections, gaining insight into community change, and expanding his collaborative experiences. Hear more from Nasir below.

Responses have been edited for clarity and readability.

Nasir N., NC InCK Youth Council member
Nasir N., NC InCK Youth Council member

 

When talking about the adolescent and young adult population, what does "Strength-Based" action mean to you?

Nasir: I believe that in being Strength-Based, NC InCK promises not to undermine the talents, skills, and strengths that the parents, communities, and youth they serve already hold. Instead, NC InCK will identify and uplift individual strengths while working to overcome any weaknesses.

In the youth population, this means finding the unique talents of a community member and supporting them as they explore and build on that skill. This may include introducing the youth to possible career paths, extracurriculars, and opportunities outside of what would otherwise be found.

 

Why is it important that we focus on the adolescent and young adult experience?

Nasir: Often, the trajectory of someone’s life is determined by their childhood and adolescent experiences. Of course, this trajectory can be changed later in life with hard work and determination, but it is far more difficult.

Supporting adolescents and young adults during this time in their lives is the best way to help those who may have had a worse hand dealt to them.

Nasir with his keyboard and composing equipment
Nasir with his keyboard and composing equipment

How have monthly Youth Council meetings impacted your understanding of child and family-led community programs and partners?

Nasir: With resources like frequent guest speakers, the monthly Youth Council meetings have helped me learn more about programs within the community. Through this interaction, I’ve learned over time what these types of programs provide and who they support.

How does the Youth Council help NC InCK incorporate the adolescent and youth-adult experience into their decision-making?

Nasir: The Youth Council helps NC InCK consider the adolescent and youth-adult experience by including multiple youth voices who all offer a unique perspective. It is important to incorporate different viewpoints into the decision-making process. Our strength ultimately comes from the collaboration between the Youth Council and the larger NC InCK organization, both of which have the common goal of equitable assistance.

Bringing NC InCK Care Management Insights to a National Audience

Posted on by manda.hufstedler@duke.edu

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.

Co-Presenters Stephanie Turner, RN, MSN, Vice President of Population Management for UNC Health Alliance; Eleanor Wertman, MPH, Care Integration Director for NC Integrated Care for Kids; and Tara Kinard, DNP, MSN, MBA, RN, CCM, ACM-RN, CENP, Associate Chief Nursing Officer, Duke Population Health Management Office before their NAACOS presentation
Co-Presenters Stephanie Turner, RN, MSN, Vice President of Population Management for UNC Health Alliance; Eleanor Wertman, MPH, Care Integration Director for NC Integrated Care for Kids; and Tara Kinard, DNP, MSN, MBA, RN, CCM, ACM-RN, CENP, Associate Chief Nursing Officer, Duke Population Health Management Office before their NAACOS presentation

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:

website headshots_our team (10)

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.