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

Posted on October 20, 2026October 20, 2026 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 October 23, 2025 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 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, 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 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 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 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 October 10, 2025October 10, 2025 by Lindsay Kenton

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.”

Description

The NC InCK team discussed school supports, collaboration, and holistic care management during their second conversation about Schools in the September 2023 Integrated Care Rounds.

Click this link for the September 2023 Schools Integrated Care Rounds Slide Deck.

Key Takeaways

Family Navigators are Connectors: Due to the large amount of time students spend in school, collaborating with the school system can help increase access to services that address social, behavioral, and health needs. School personnel are with the student daily and can help a family accept a referral or engage in care management.
Family Navigators are Advocates: School supports such as Individualized Education Program (IEP) and Section 504 Plans are underutilized in North Carolina! In the U.S., NC ranks 46th in providing appropriate in-school support and accommodations for children with mental health needs and 50th in suspending children with disabilities. These statistics disproportionally affect Black students. Effectively communicating a child’s educational needs empowers families to speak up if they are not being met.
Family Navigators Understand: Asking the right questions, and listening to children and families can reveal challenges such as bullying, housing insecurity, absenteeism and more. Understanding these experiences will ensure holistic care management supports are in place.

Resources

NC Center for Afterschool Programs – Website that allows you to search for afterschool programs by zip code and filter by grades served and activities offered.
Just U & Me Mentoring Program – A mentoring program that engages Vance County fifth-grade students in social-emotional intervention strategies that will help them improve classroom participation and academic success; meets weekly on Saturdays from 9am – 12pm.
Durham Performance Learning Center – A program that helps high school students who aren't succeeding in traditional school get back on track for graduation in small classes with 1:15 teacher student ratio. Students may be recommended by current/ previous school, but families can apply independently as well.
ICR Appendix – Several resources listed including IEP/ Special Education Guides, before and after school programs, school resources by NC InCK County, and education related Value Added Benefits offered through each PHP.

NCINCK

NC Integrated Care for Kids

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