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NCCARE360 in Rural NC

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On January 5, Samantha Kummerer of ABC11/WVTD reported that in Franklin County, Annette Strong spent weeks trying to arrange transportation for her husband, Jeffery Strong, to get to his dialysis appointments three times a week at a clinic just 12 minutes away in Wake County. He is unable to walk and can’t see, which means transportation isn’t as easy as getting in the family’s car. Jeffery needed a transportation company that could provide a stretcher or wheelchair, travel outside of the county, and bring him to dialysis centers. After the company, HealthFirst Transport, was no longer able to provide these services, the Strong family had very few options left.

Resources do not exist to serve counties’ growing population and social needs, companies and organizations providing services are short staffed, and exorbitant rising costs of services are just a handful of the issues that many rural residents often face when attempting to access health care in their communities, leaving them feeling as though they are falling through the cracks.

When asked how these issues can be addressed at the state level, Foundation for Health Leadership and Innovation’s (FHLI) President and CEO, David Reese, highlighted the work that FHLI is doing to bring patients and communities together to begin to tackle issues like transportation that were highlighted during the pandemic.

“Part of what we do at the Foundation for Health Leadership and Innovation is spending time with rural communities helping them begin to identify how they are addressing challenges, working toward solutions, and then helping them create alignment and then leverage the access that we have so that they can really begin to think about whole-person health and not just the one issue of transportation,” explained Reese.

North Carolina is nearly twice as rural as the national average, with about 40% of our NC residents living and working in rural areas. Those citizens face unique challenges that are less common to folks in urban areas. The NC Rural Health Association (NCRHA) developed the 2022 NC Rural Health Snapshot to highlight opportunities to improve health in rural communities. The NCRHA is the affiliate of the National Rural Health Association and is housed within FHLI. The Association focuses on all issues affecting our rural communities including access to healthcare and hospital closings, adequacy of healthcare networks, limited broadband and challenges related to housing, food, education, employment, and transportation.

FHLI’s Community Voice team values the voice of our rural community partners and authentically listens to them. The team uses this feedback to help rural communities figure out ways to improve their challenges or to connect them with other organizations and resources that are more appropriate and equipped to make a difference. This is where NCCARE360 can be utilized.

As the first statewide coordinated care network that better connects individuals to local services and resources to help meet these needs, NCCARE360 provides a solution to a fragmented health and human services system by connecting providers and organizations across sectors in a shared technology network where they can electronically refer individuals and families who have unmet needs to community resources. “We assume that everyone knows every resource that is available back within their community and that is just not always the case, and this is part of North Carolina coming back together,” Reese said.

Reese said the NCCARE360 Network allows North Carolinians to think differently about how they connect and become healthier, and he is optimistic that solutions will be forged in North Carolina communities over time. “This is it’s not a 60-yard dash; this is the marathon. This is how we rebuild after COVID but this is also about how we create the pathway for healthier North Carolinians.”

NCCARE360 Honors Staff Sergeant Shauna Perkins on Veterans Day

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Happy Veterans Day! NCCARE360 would like to thank everyone who has served our country, including FHLI & NCCARE360 finance manager, Shauna Perkins.

Shauna is a veteran of the North Carolina Army National Guard with 12 years of service, including two tours to Iraq in support of the Global War on Terrorism. She joined the Foundation for Health Leadership & Innovation in 2021 as Finance Manager. She has worked in both nonprofit and corporate environments and has significant experience in finance. In her role at FHLI, Shauna supports the VP of Finance and Administration with strengthening and aligning the fiscal functions of FHLI. Shauna also supports NCCARE360 program finances.

She joined the NC Army National Guard when she was 17 years old as a means to pay for college. In 2004, she was deployed to Iraq for the first time. She was the first female soldier in her unit as they realigned from infantry to quartermaster. Despite feeling shocked and a little anxious at the thought of deployment, she found that the high morale of her brothers and sisters in arms helped her get through that first year overseas. During her tenure, Shauna worked as a 92F Petroleum Supply Specialist, and her superb administrative skills allowed her to quickly move up the ranks to staff sergeant.

Back in the states, she earned her associates degree in May 2008 and had just begun working a corporate job when she received a call in August 2008 to re-deployed back to Iraq in March 2009. She didn’t let that get her down though, because she ended up buying her first house in the states while she was still stationed in Iraq!

Shauna completed her service and received an honorable discharge in August 2011. She now holds a Master of Business Administration degree from The University of Mount Olive and a Bachelor of Science in Accounting from North Carolina Wesleyan College. Thank you, Shauna, for bravely serving our country.

FHLI and NCCARE360 are honored to have you on our teams!

Happy Veterans Day from NCCARE360

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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.

https://veteransbridgehome.org/

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.

Greensboro Housing Coalition: Partner Spotlight

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The support and input from our amazing partners in the health and human services field is instrumental to the success of NCCARE360 in North Carolina. Today, we are sitting down with Robbielene Lawhorn, at Greensboro Housing Coalition to discuss the organization’s achievements, experience with the network, and vision for the future.

How would you summarize Greensboro Housing Coalition’s work and your role in particular? What populations does Greensboro Housing Coalition serve?

The Greensboro Housing Coalition is an agency that is concerned with safe and affordable housing. We believe that everyone has the right to stay in a decent place that they can afford. Most days, we find ourselves acting as a triage point for people about a wide variety of housing situations. We listen to the concerns of the community and we work to provide counseling and solutions. In some instances, we address their concerns through programs that we offer and also often have to refer them out when there are circumstances that GHC may not be able to address. My role as the Homeless Prevention Team Manager is directing my team as we field phone calls and see clients face to face regarding their housing issues. Our agency serves anyone. We get calls from all over the U.S. regarding housing concerns. Most of our clients have low income and are in crisis when they walk through our doors or call us.

Currently, what’re your biggest challenges at Greensboro Housing Coalition? How do you deal with them?

The biggest challenges that we have at GHC are the scant funding resources that we can tap into for our clients for things such as emergency assistance or eviction prevention. The other huge issue is the lack of enough safe and affordable housing properties that we can direct people to. We help clients think out of the box to find monetary resources and negotiate what they might owe and/or need. Like most communities, Greensboro is under-resourced to deal with the types of crisis that vulnerable people find themselves in on a daily basis. According to recent data, Greensboro ranks #7 nationally for numbers of evictions.  

What accomplishments are your team most proud of?

The thing that I am most proud of for my team and GHC as a whole is that we rise to the occasion in times of need. When there is a disaster, such as the tornado that hit Greensboro in April of 2018, when a multi-unit apartment complex was condemned, and when properties have been flooded or there has been a fire leading to condemnations through no fault of the resident, we help to re-house people. During times of large and small scale housing emergencies, GHC is one of the first agencies, and in some cases the only agency, that is called upon to analyze what is happening, develop a plan of action to help the person/people affected and to implement that plan. We work closely with other community partners to help our clients, if and when necessary. Our GHC staff stays ready and willing to help out in any way that we can.

How has NCCARE360 impacted the way you deliver care? What has surprised you?

The use of NCCARE360 has allowed us the ability to be able to reach people who might not have ordinarily contacted us because they were unaware of our agency, through referrals from other member agencies. We have received many more referrals from healthcare partners than before. 

What was it like for your organization before working with NCCARE360? And afterward?

We have always been an agency that people referred their clients, friends, and family to for possible help. Now, we are reaching more people. We strongly appreciate the feedback loop that is built into NCCARE360 between agencies making and receiving referrals. In the past, referrals have come our way for things that we can’t or don’t do, and the clients have had to come to us to find this out. NCCARE360 has streamlined things for the consumer, saving them time so they don’t need to use resources to travel to an agency that might not be able to help them. 

What advice would you give to an organization interested in joining NCCARE360?

I would suggest that any organization join because it will give them access to potential clients who might not have ever known about them. It also provides possible resources that they could refer their own clients to. With more resources, people’s situations may be resolved quicker.

What’s next for Greensboro Housing Coalition?

GHC is working to build relationships with NC’s Prepaid Health Plans and is working to be part of Medicaid Pilots if our region is selected. We believe that there has already been a demonstrated health benefit of going upstream to address social drivers of health and we want to continue to help push conversations about the most effective ways to deliver care and serve vulnerable people.

We hoped you enjoyed our NCCARE360 partner spotlight interview. Get inspired by Greensboro Housing Coalition and learn more about their work at www.greensborohousingcoalition.org.

Temple: Partner Spotlight

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The support and input from our amazing partners in the health and human services field is instrumental to the success of NCCARE360 in North Carolina. Today, we are sitting down with Tiffany Joseph, Ministry Assistant at Temple to discuss their achievements, experience with the network, and vision for the future.


How would you summarize Temple’s work and your role in particular? What populations does Temple serve?

Temple is a church that loves everyone in our community. We offer Celebrate Recovery and homeless outreach, as well as being a church that believes in God’s word. I am Celebrate Recovery Ministry Assistant. I take all of our CR calls and am available 24 hours a day for that purpose. Additionally, I help with the ministry at the church, go to community meetings, and work one-on-one counseling women. We serve our whole community as CR is a 12 step program for any hurt, habit, or hang-up which can include drugs, alcohol, anxiety, depression, codependency. It’s literally for anything someone might have an issue with. We also serve in the women’s prison in Raleigh, NC and two men’s prisons in Harnett County.

Currently, what’re your biggest challenges at Temple? How do you deal with them?

The biggest challenge at the moment, is not enough people knowing that Temple is involved with NCCARE360. We really need to work on getting the word out for this great community service. Thus, we will be adding this information to our Friday night announcements. 

What accomplishments are your team most proud of?

As a team member at Temple, I am very proud of the fact that we are reaching out to those others often neglect, ignore, and judge. Showing love to all is very important to us.

How has NCCARE360 impacted the way you deliver care?

NCCARE360 has given us the necessary tools to help those in need find help to improve their lives – be it clothing, food, job search, etc. It is so wonderful to be able to see the process from start to finish and know that a person that came to us for help got what they needed. 

What was it like for your organization before working with NCCARE360? And afterward?

Before, it was just a conversation of trying to tell someone where they could maybe get help. Now, we have the tool to know where that help is available. It is so wonderful to have this at our fingertips.

What advice would you give to an organization interested in joining NCCARE360?

Please join and help your community to serve those in need. The more organizations we have, the more people we can help.

What’s next for Temple?

We are in the process of finding a property for a Dream Center for families in a domestic violence situation. At this center, we hope to assist those affected by having a safe place to stay, help with education needs, clothing needs, and eventually helping them find a new home.

Anything else you would like to add?

I am so excited for what the future holds for Temple, our community, and NCCARE360. We can achieve so much when we all work together for the greater good.


We hoped you enjoyed our NCCARE360 partner spotlight interview. Get inspired by Temple and learn more about their work at http://www.templerepresents.com/. If you would like to contact our Community Engagement Team, please fill out the form located here.

NCWorks: Partner Spotlight

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The support and input from our amazing partners in the health and human services field is instrumental to the success of NCCARE360 in North Carolina. Today, we are sitting down with Renee Hinton, Assistant Center Manager at NCWorks Career Centers Clayton to discuss their achievements, experience with the network, and vision for the future.


How would you summarize NCWorks’s work and your role in particular? What populations does NCWorks serve?

NCWorks Career Centers assist people with training and employment and everything in between. We provide one on one assistance with resume writing, career counseling and exploration, job search, training, interviewing, etc. We connect people with jobs and connect talent to employers’ job openings. We can assist employers with labor market data, staffing challenges, employee/applicant skills gaps, and outplacement services. Our center serves the adult population, while the youth population is served by NCWorks NextGen Centers. Our services are free to applicants and employers. At NCWorks Career Center Clayton, my role is to assist in the center’s operations, oversee staff, assist customers, coordinate programs/activities, work with partner agencies, etc.

Currently, what are your biggest challenges at NCWorks? How do you deal with them?

Our biggest challenge currently is matching the skills of people with the requirements of the positions available. However, we have a variety of programs to bridge this gap. We provide opportunities for educational training, work experience, on the job training, and apprenticeships. We also offer free workshops on a variety of subjects and to a variety of populations. We also face marketing challenges, as most of our marketing is through word of mouth. NCWorks – Clayton has only been in the area for a few years, but we are always happy to try to spread the word of who we are and what we do.

What accomplishments are your team most proud of?

Our awesome staff serves an average of 600 people a month in our office. In addition, we have customers who connect with us through our website or call center. We are very proud of our work and that it helps citizens to not only be productive contributing members of our community, but also helps them to provide for their families. As for the employers, we are happy we are able to assist them to grow and stay in North Carolina.

How has NCCARE360 impacted the way you deliver care? What has surprised you?

Before NCCARE360 we used a notebook of resources which we had to update regularly and became cumbersome and time consuming. NCCARE360 provides one place to go for resources. We are able to make multiple referrals in a short amount of time knowing the information is current, and the receiving agency will respond. I believe the NCCARE360 is a great resource, and the surprising part is how easy it is to use. It is very user friendly in my opinion.

What was it like for your organization before working with NCCARE360? And afterward?

Before NCCARE360, we could make a referral and not necessarily know if the person received help unless we followed up and spoke with the agency or client. Now we are able to follow the progression in NCCARE360. 

Based on your experiences so far, how do you see NCCARE360 impacting the standard of care in North Carolina?

Once the system is expanded to cover North Carolina, I can see us making referrals to anywhere in the state for our clients! Many citizens do not stay in one place and may move around. This will allow us to be able to connect people with resources anywhere in the state easily and efficiently. It allows our state to be connected on a resource level that has not been available before. There are many resources available in NCCARE360, and it is a database that can expand as time goes. Allowing all of North Carolina to be connected in assisting our citizens with many needs across our fine state. 

What advice would you give to an organization interested in joining NCCARE360?

Join! It is such an easy way to connect your clients with resources across the state. It also allows providers across the state to connect with you — a win-win situation for providers and clients. Send referrals through NCCARE360, and we will be glad to help your customers as well. 


We hoped you enjoyed our NCCARE360 partner spotlight interview. NCWorks Career Center – Clayton is located at 8988 US Highway 70, Business West Suite 100, Clayton, NC 27250. You can visit them at their office or visit the NCWorks website, a statewide database for applicants and employers, at NCWORKS.GOV. If you have any questions about their services, please call the Clayton office at (919)-553-0953. If you would like to contact NCCARE360’s Community Success Team please fill out the form located here.