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.
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:
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.
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 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.