This April, we’re commemorating the passing of the Fair Housing Act and honoring National Fair Housing Month by raising awareness of the importance of equal access to housing and by recognizing the progress that has been made in the fight against housing discrimination.
Housing stability has a significant impact on health outcomes, as there are many ways in which a lack of housing or poor-quality housing can negatively affect health and wellbeing. Experiencing housing instability may contribute to stress, anxiety, or other mental and physical health issues. Housing is a foundational resource that everyone needs. One goal of NCCARE360 is to provide access to resources to address housing needs. While housing services can be a complicated landscape, we aim to streamline the referral process and connect to coordinated referral systems that already exist. Late last year, NCCARE360 began piloting a Housing Referral Determination Screener built directly into the Unite Us Platform. This screener can assist network organizations in understanding what resources a person may be eligible for to address their housing crisis, with the goal of providing clarity about eligibility for housing programs and increase the quality of referrals to housing agencies and homeless service systems.
In addition to streamlining housing referral services, NCCARE360 has the potential to improve the overall quality of care for individuals and families by facilitating collaboration among service providers and ensuring that all needs are being met. This comprehensive approach to care is especially important for those experiencing homelessness or housing instability, as they often face complex and interconnected challenges.
Rachel Waltz, Program Manager at Orange County Partnership to End Homelessness, uses NCCARE360 to help clients experiencing homelessness. Rachel has always had an orientation toward what felt just and fair as well as an interest in being an agent of change in her community. She decided to explore social work as an avenue of change for individuals, families, and communities when she learned the young people in her therapeutic wilderness program were returning home without the proper social supports needed to continue their growth and development. She now works to end homelessness because she knows that the housing crisis can affect any of us.
NCCARE360 fosters collaborations between service providers and people experiencing homelessness, which Rachel sees as the foundation of our success as a community. NCCARE360 is also allowing for a more equitable lens through which to help. She notes that the people who experience a housing crisis that is unable to resolve on its own are disproportionately Black and African American folks, and this inequity is happening because of policy decisions that have a harmful and persistent legacy.
“The NCCARE360 network enables us to pair folks with the right resources at the right time.” –Rachel Waltz
Rachel says NCCARE360 has been a game changer in terms of looking at how referrals can be sent through the service provider networks in addition to the Orange County Housing Helpline. To successfully find and keep housing once in the formal homeless service system, most folks need a navigator who can help connect them with the right resource at each stage in the process. The Partnership depends on service providers to help make informed referrals to ensure that someone with complex needs receives a higher level of assistance. The NCCARE360 network has enabled the Partnership to continue to focus on some of most vulnerable community members while offering a lighter touch to community members who can successfully meet their housing needs with less intensive intervention.
As we celebrate National Fair Housing Month, it is important to remember that equal access to housing is a fundamental human right. NCCARE360 is a tool that can help us move closer to that goal by streamlining the housing referral process and improving access to the resources individuals and families need to achieve stable housing and a brighter future.
March is National Social Work Month, a time to recognize and celebrate the important role social workers play in supporting individuals, families, and communities. Social workers are professionals who are trained to help people overcome challenges and improve their well-being through a wide range of services, including counseling, case management, advocacy, and community outreach.
Social workers often find it challenging to connect their clients with the right resources and services to address their needs. They are frequently assisting clients with complex cases who require support from multiple providers and organizations. Fragmented systems make it difficult to navigate the complex network of community resources and services that are available. Fortunately, NCCARE360 is making it easier to send referrals for community resources and collaborate with other providers. Social workers can use the platform to quickly and easily refer clients to a wide range of services and resources, including housing assistance, food pantries, transportation services, mental health services, and more.
Because NCCARE360 has the ability to track referrals and outcomes, social workers can monitor the status of their referrals and see if their clients successfully accessed resources, helping to ensure their clients are receiving the support they need to improve their health and well-being. In addition to making referrals to community resources, NCCARE360 also facilitates communication and collaboration among providers. Social workers can use the platform to communicate with other providers and share information about their clients’ needs and progress. This can help ensure that all members of a client’s care team are working together to provide the best possible support.
This month, we are highlighting Leslie Craver, an incredible social worker who utilizes the NCCARE360 network daily to connect their clients to needed social supports and services.
Leslie Craver is a part-time Family Caregiver Specialist at The Life Center of Davidson County, an organization that provides high quality daytime care to older and impaired adults in Lexington, NC. Her interest in social work began in college and led her to a 30-year career with NC Department of Social Services, where she worked mainly in adult services. As a Home Adult Specialist, she monitored adult care homes and investigated any issues that arose in adult care. When it came time to retire, joining The Life Center was a natural fit for Leslie. At the same time, The Life Center was awarded a health equity grant from FHLI to increase their utilization of NCCARE360. Leslie trained on the platform and now uses NCARE360 to connect their residents to needed resources.
“I spent a lot of my time in DSS linking people to resources, so it wasn’t a big jump for me, just a different platform to do so.“ -Leslie Craver.
Leslie states NCCARE360 has helped expand her knowledge of resources not just in Davidson County but throughout the state, and she believes the next important step is helping other community organizations like The Life Center understand the value of the NCCARE360 program so they will be just as eager to join the network. “When you have multiple people come and go from different agencies, it’s a useful tool to not have to make a lot of phone calls. You can just look in the system and see all the places they’ve been and if they got help or not,” she said.
Not only does Leslie use NCCARE360 to connect The Life Center’s clients to resources, but she also makes visits to elderly people in the community who are unable to leave their homes and to the caregivers of those who cannot be left alone. She reaches out with food vouchers, PPE bags and other needed items, and she’s even provided some shopping for elder community members using those food vouchers. Then she enters those services in NCCARE360 and provides additional assessments for any other unmet needs that she can assist with.
“The Life Center is the best,” Leslie declared. “They do great work and tried to reach out even before NCCARE360, and this is just another way they are working to expand.”
National Social Work Month is an opportunity to recognize the important work that social workers do to support our communities. NCCARE360 is a useful tool that is helping them make referrals to community resources and collaborate with other providers to address the complex needs of their clients. By leveraging technology and working together, social workers can help ensure that everyone has access to the resources they need to thrive. NCCARE360 is grateful for the hard work and dedication of all social workers who help improve our communities.
This Black History Month, we are honoring our Black community leaders and spotlighting Natreace Buie, NCCARE360 Referral Manager for The Arc of North Carolina. Natreace is passionate about helping people in her community and she talked to us about how she is able to better support them through her use of the NCCARE360 network.
Natreace graduated from Queens College of CUNY in New York with a major in sociology and a goal of helping others, especially those who needed an extra helping hand. She finds personal and professional fulfillment in providing guidance to people and advocating on their behalf when they are unable to do it themselves. Having two family members with intellectual disabilities helped put her on her career path when she witnessed just how difficult it was to connect them to healthcare providers or community support and resources because of the isolated and fragmented care systems. She found her calling when she realized she could use her experience and skills to help reduce that burden not only for her family but for other North Carolina families experiencing the same struggles.
“It is definitely my calling because it fills me when I’m able to help someone.”
Natreace is the NCCARE360 Referral Manager for The Arc of North Carolina where she supervises the referral journeys for their clients. The Arc of NC provides direct support and services to individuals with intellectual disabilities to enable them to live fully and independently in the community. When The Arc of NC needed someone to implement the NCCARE360 network using the Unite Us Platform, she once again felt that calling. Natreace brought her years of experience working in a variety of roles ranging from providing direct support to individuals in group homes, to working as a coordinator in the health care sector, connecting them all to care and resources that would make their lives a little easier. All these roles have allowed her to provide guidance to those who need it most.
“When I learned [about the NCCARE360 network] I was like, ‘hold on […] to be able to identify the need and to connect our individuals to organizations and to close the loop is phenomenal. With one click!’ It’s phenomenal what the NCCARE360 network offers.”
Natreace also appreciates how the NCCARE360 network addresses health equity by allowing her to identify unmet needs in the community and then reach out to help close those gaps. The network allows her to pull data and graphs to visualize what is missing, where those missing supports are needed most, and when one demographic may need more help than others.
Natreace is excited to see how the NCCARE360 network continues to grow in the future. As she put it, “teamwork makes the dream work and we do it one referral at a time.” Thank you, Natreace, for all of the work you do to help others, and for being a valuable member of our community!
NCCARE360 is the first statewide social needs referral platform in the country coordinating referrals for more than 100,000 North Carolinians to needed services since its creation in 2019
Cary, North Carolina – NCCARE360, the first statewide coordinated care network in the country that better connects people to local services and resources has reached a new milestone with more than 100,000 people in North Carolina being referred for services through the platform since its implementation in 2019.
NCCARE360 is the first statewide network that unites health care and human services organizations, assesses for and identifies unmet social needs, and enables a coordinated, person-centered approach for delivering care in North Carolina. NCCARE360 is the result of a strong partnership between the NC Department of Health and Human Services (NCDHHS) and the Foundation for Health Leadership & Innovation (FHLI). The NCCARE360 implementation team includes United Way of NC, NC 211, Unite Us, and Expound Decision Systems.
The referral for the 100,000th person was part of the rollout of the Healthy Opportunities Pilots, the nation’s first comprehensive program to pay for non-medical services, such as food and housing, for Medicaid enrollees. A community-based nonprofit providing inspections for housing safety and quality was able to provide high-priority repairs for home accessibility and safety modifications from a referral made securely through the platform.
In May 2019, one of the first referrals through the NCCARE360 Platform powered by Unite Us resulted in an individual finding employment assistance. For NCCARE360’s 1,000th referral, a Piedmont resident was referred to social services by a local health department’s WIC & Nutrition services and was able to receive help with diapers, bedding, and other necessities for their home.
“To be healthy, it is essential to have access not only to medical care but also to non-medical drivers of health like food and housing”, said Dr Elizabeth Cuervo Tilson, State Health Director and Chief Medical Officer for NCDHHS. “NCCARE360, a shared infrastructure across the state, continues to be a critical tool that improves coordination and enables a focus on whole person health.”
Platform trends show that as of November 30, 2022, the top five service needs by volume statewide were food assistance, housing and shelter support, individual and family support (e.g., childcare assistance), income support (e.g., emergency/one-time financial assistance), and utility bill payment assistance.
In addition to serving more than 100,000 people statewide, the NCCARE360 team continues to grow and support the network —especially in rural and under-resourced areas—to increase the capacity and efficiency of communities to respond to referrals. The NCCARE360 network has now surpassed 3000 organizations onboarded onto the platform and 7,500 active programs to which referrals can be made. With almost 50,000 network users actively sending and receiving referrals, almost 80% of accepted referrals are accepted in 4 days or less. 92% of referrals made as part of the Healthy Opportunity Pilots were accepted in fewer than 3 days.
“The purpose of NCCARE360 is to improve the health and well-being of all North Carolinians by recognizing there are many aspects that affect our health,” said David Reese, President and CEO of Foundation for Health Leadership & Innovation. “Today’s announcement is an important step in achieving this purpose.”
Organizations interested in joining NCCARE360 as a network partner can visit www.nccare360.org for more information. People who are interested in making a connection through NCCARE360 can visit https://nccare360.org/resources/ to request assistance.
This Veterans Day, NCCARE360 is highlighting one of our respected network partners working with veterans and their families: Veterans Bridge Home.
Each year, Veterans Day offers an opportunity for Americans to honor all military service members who have served our country. It’s a day to recognize and give thanks for their courage, determination, and loyal service to the United States. With North Carolina being home to 12 military installations and over 730,000 veterans, NCCARE360 proudly joined forces with NCServes in July 2021 to ensure our state has a strong network of resources for its military and veteran community. NCServes is the country’s first coordinated system of public, private, and nonprofit organizations working together to provide support to military members and their families, and is used by many veterans-serving agencies, like Veterans Bridge Home, to coordinate health care and human services for this population.
We know that approximately 200,000 service members leave active duty each year and veterans are more likely to report health issues such as diabetes, smoking, heavy alcohol use, mental illness, post-traumatic stress disorder, and other chronic illnesses than those on active duty. These behaviors and conditions place veterans at greater risk for chronic diseases that are best managed by interdisciplinary teams. In North Carolina, the top service needs experienced by the veteran population include housing and shelter needs, employment and financial assistance, benefits navigation, and food assistance. Veterans Bridge Home is one organization working to link veterans and their families to the community and to resources that address these social needs.
Veterans Bridge Home serves as an entry point for veterans who don’t know where to turn to access support and services. They connect veterans and their families to the community through their network of partners and help them navigate needs like employment, create social connections, and settle their families by connecting them to the resources they need to be successful and thriving leaders in our community. Paul Berry served in the United States Marine Corps for 30 years, retiring as a Command Sergeant Major, and has been the Regional Network Director at Veterans Bridge Home for the past two years. He has been doing this type of work for more than half a decade. He highlighted some of the major ways that NCCARE360 has positively impacted the work of Veterans Bridge Home, which in turn helps to improve the health and wellbeing of our veteran population.
NCCARE360 helps assess for and identify unmet social needs through embedded screening questions built right into the platform. The screener assists network organizations in understanding what resources a person may be eligible for so they can make the best referral possible. Prior to the creation of NCServes and NCCARE360 organizations often tended to address one need at a time. For example, if a veteran presented with a request for housing, the organizations would tackle that need without questioning other potential needs. However, NCServes quickly realized that these veterans were returning because only one part of their need had been addressed—housing—when they also had transportation and food needs. Thanks to the screeners, coordinators at Veterans Bridge Home are now able to get veterans to the right services or resources, ensuring that whole-person health and well-being is addressed.
Paul also explained that unification with NCCARE360 has allowed Veterans Bridge Home to begin addressing family needs, as well. The NCCARE360 Network includes Resource Navigators supported by NC 211 who can support complex referrals and stay with a client through the referral process if needed. Veterans Bridge Home can now refer veterans’ partners, children, and other family members with identified social needs to the NCCARE360 Navigators who can connect them with services and resources available to civilians. Before unification, they were only able to refer clients to military resources.
“Yes, we work with that specific population of veterans and we’re proud of that, but we also know that if there are other stressors in that home, we want to be part of that solution and the NCCARE360 Navigators and NC 211 have been great partners in addressing those needs,” – Paul Berry, Regional Network Director, Veterans Bridge Home.
Another unexpected yet welcome benefit to joining the NCCARE360 Network has been an increase in funding opportunities. Through their partnership with NCCARE360, Veterans Bridge Home has been able to apply for and receive two new grants. They are the recipients of the NCCARE360 Health Equity Grants that were funded through the CDC’s COVID-19 Health Disparities Initiatives grant, which they are using to fund staff members, operational expenses, and event costs. They are also one of only two coordination centers to receive the Staff Sergeant Parker Gordon Fox Suicide Prevention Grant, which is their largest grant to date. This additional funding will allow them to continue to grow their capacity to better serve more veterans and their families.
Plugging into the NCCARE360 Network meant Veterans Bridge Home has also connected with other community organizations in the network, growing their partnerships and civic relationships. Paul found that the top 10 organizations sending referrals to Veterans Bridge Home has changed since joining the network, where many of the senders are no longer veteran-only serving organizations, but rather those that serve communities at large. Building relationships with these agencies helped change the playing field and allowed Veterans Bridge Home to embrace the no-wrong-door approach to care coordination. Now, if they receive referrals for non-veterans, they know they can refer them to an organization in the NCCARE360 Network or even to the NCCARE360 Navigators; they’re happy to use the opportunity to make their community partners aware of the federal money available for veterans that frees up local or state funding for civilians, helping to guarantee the best use of resources. Paul attributes this success to capabilities of the NCCARE360 network and technology.
Veterans Bridge Home is a staple among the military community, providing veterans and their families an opportunity to better navigate their unique social needs. They are also creating social connections to the communities and resources veterans need to be successful, healthy, and whole. This Veterans Day and every day, NCCARE360 is proud of the impact Veterans Bridge Home is making and we are honored to have them as a network partner.
Be sure to visit their website to learn more about their work and how you can help support NC’s veteran population and their families.
About NCCARE360 NCCARE360 is the first statewide network that unites health care and human services organizations with a shared technology that assesses for and identifies unmet social needs, and enables a coordinated, community-oriented, person-centered approach for delivering care in North Carolina. NCCARE360 is the result of a strong public-private partnership between the NC Department of Health and Human Services (NCDHHS) and the Foundation for Health Leadership & Innovation (FHLI). The NCCARE360 implementation team includes United Way of NC, NC 211, Unite Us, and Expound Decision Systems.
Contact For more information about NCCARE360, or any of its partner organizations, please send an email to connect@nccare360.org.
