To achieve high-value care, support development, and create positive health outcomes for children and youth, we need a system that addresses not only physical health but also behavioral, social, and educational needs.

NC InCK pursues these goals by:

• More holistically understanding children’s needs by using data from health, social, and educational sectors to identify children and youth who could benefit from additional support.
• Supporting and bridging services for children with higher needs by providing direct care management support to children and families. NC InCK Integration Consultants also provide ongoing capacity-building and resources to help NC InCK care managers address the full spectrum of children’s health-related needs.
• Focusing Healthcare investments by implementing an alternative payment model that links healthcare payments to meaningful measures of child well-being. child well-being.

Medicaid-insured children in NC InCK’s five counties who are identified as being at risk of potential adverse health or developmental outcomes are eligible for NC InCK care management. NC InCK care managers, known as Family Navigators, contact the families of eligible children to offer up to a year of care management services. Family Navigators work with families to set goals, track progress, and connect to clinical and community services that promote child well-being. Family Navigators also work with families to identify and bring integrated care teams together. They will then share relevant health information across these teams to improve communication and ease caregiver burden.

The NC InCK Alternative Payment Model (APM) promotes child-centered care by incentivizing the delivery of high-value, whole-child pediatric care. NC InCK’s APM measures incentivize both traditional clinical activities and the provision of other services that are not traditionally reimbursed in fee-for-service payment approaches (e.g. referring to Pre-K and community literacy programs or screening and making referrals for housing and food insecurity). Primary care providers at Community Care Physicians Network, Duke, and UNC practices will receive actionable data on the APM’s novel child-centered measures annually.

Any provider caring for an NC InCK-attributed child (i.e. ages 0 through 20 with Medicaid in one of our five counties) can participate in NC InCK. Healthcare providers can refer children for NC InCK care management and support the care management process as part of a child’s integrated care team. As a member of an integrated care team, you will have access to the child’s care plan and contact information for any individuals engaging with your patient. Additionally, health care providers within some health systems can participate in the NC InCK Alternative Payment Model (APM) by documenting actions associated with NC InCK APM measures. For information about the NC InCK APM and/or referring a patient to care management, email info@ncinck.org.

NC InCK has been designed in close collaboration with North Carolina Medicaid and aligns with many aspects of Medicaid Transformation (e.g., risk stratification, care management services, and quality measurement to drive high-value care). NC InCK builds upon Medicaid Transformation’s focus on whole person health by adding child-focused resources and providers to improve whole-health outcomes for children and their families. NC Medicaid continues to support NC InCK to ensure seamless integration with broader transformation activities.

NC InCK is distinct from the Healthy Opportunities Pilots. NC InCK serves children in five counties (Alamance, Durham, Granville, Orange, and Vance) that do not overlap with the counties awarded the initial HOP grants. The funding that supports NC InCK is different from the funding for the HOP.