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May 19, 2023
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Champion Highlight: Richard Johnson, Person County Health Department

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Richard Johnson, MS, CHES®, TTS, is a busy man. As a public health educator for Person County Health Department (PCHD), he is involved in several projects designed to help his community lead healthier, happier lives. He gives presentations on respiratory care, speaks about the importance of high-quality sleep for good health, teaches cardiovascular disease prevention in women, and promotes tobacco and smoking cessation, just to name a few. He also uses NCCARE360 to connect individuals and families in his community to much-needed services and resources.

Richard Johnson, MS, CHES®, TTS

Richard has worked in healthcare for more than 30 years, but it was when he began working as a Community Health Worker (CHW) two years ago that he really came to understand the importance of community partnerships in improving health outcomes. During the COVID-19 shutdowns, he spent a lot of time going into communities to locate individuals and families suffering hardships caused by the pandemic. This is when he was introduced to NCCARE360 and found that it was an easily navigated referral system that enabled him to connect community members with needed resources. In March 2022, he came to PCHD to lead his department’s onboarding to NCCARE360. Richard said the onboarding process for their department may have been more involved due to their number of programs and users (seven separate programs and 17 platform users), but they started the initial inquiry of onboarding in September 2022, completed all training in November 2022, and received their first referral in December 2022.

 

 

In March 2023, Richard coordinated an information meeting to introduce NCCARE360 to the Person County community. He worked with PCHD’s Equity Advisory Council to invite a variety of community-based organizations, faith-based organizations, civic organizations, African American Greek organizations, and other organizations that serve historically marginalized populations. The meeting was successful and largely attended, and a post-event survey revealed that seven organizations attending the meeting indicated an interest in moving forward with plans to onboard to NCCARE360 within the following 90 days!

Richard continues to be a strong champion of NCCARE360. In April 2023, he co-presented with FHLI and Unite Us at the Eastern District North Carolina Public Health Association (EDNCHPA) 63rd Annual Conference, detailing his experiences and successes with using NCCARE360 in Person County.

“While using NCCARE360, I saw families receive food. I saw instances where the electricity bills were paid. I saw individuals connected with legal assistance to help them avoid eviction from their homes in the dead of winter.”

Richard reports mostly positive experiences and outcomes using the NCCARE360 network, including thousands of pounds of food delivered to individuals and families, and successful COVID-19 testing and vaccination for many underserved communities. We are proud of our partnerships with local health departments like PCHD and supporters like Richard, and we are doing all we can to help them grow and succeed. Thank you, Richard & PCHD, for your continued use and support of NCCARE360. We couldn’t do it without you!

April 14, 2023
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Streamlining the Housing Referral Process

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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.

Rachel Waltz, Program Manager at Orange County Partnership to End Homelessness

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 15, 2023
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March is National Social Work Month

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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.

Pictured second from the left, Leslie Craver is the Family Caregiver Specialist at The Life Center of Davidson County. She is joined by her colleagues, Nina Smith, Jennifer Boyle, and Beth Rummage.

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.

February 16, 2023
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Our Spotlight on Natreace Buie, Referral Manager for The Arc of North Carolina

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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 Buie, NCCARE360 Referral Manager, The Arc of North Carolina

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 she worked in the health care setting, she noticed that connecting her clients to community resources required her staff to put in a lot of extra work. To make a referral, they had to research organizations in their area, and they relied heavily on Google searches and various curated lists of providers. When she learned that the NCCARE360 network took care of the legwork of compiling organizations and was connecting health care providers to community supports, she was very excited; she knew it would be an incredible benefit.

“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!

January 17, 2023
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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.”

November 11, 2022
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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!

November 11, 2022
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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.

September 29, 2022
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NCCARE360 Honors National Hispanic Heritage Month

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Hispanic Heritage Month is observed from September 15—October 15 each year and celebrates the histories, cultures, achievements, and contributions of people living in the United States whose ancestors came from Spain, Mexico, the Caribbean, and Central and South America. North Carolina’s Latinx population is now greater than one million people according to the 2020 Census; statewide, the Latinx population grew by 40% over the decade, faster than the growth of this population nationwide (23%). In fact, the Hispanic and Latinx community represents one of the fastest growing populations in the US!

At NCCARE360, we celebrate our state’s and our nation’s diverse population, but we know that there are many health inequities that afflict many marginalized communities in NC, including our Latinx neighbors. More than 7,383 (7%) of people referred through NCCARE360 have identified as Hispanic/Latinx and the top five co-occurring needs we see from these referrals are food assistance, individual and family supports that include childcare needs and peer support groups, housing and shelter needs, income support, and utilities assistance. Close to half of all cases (41.9%) since 2019 were resolved and our team works diligently to find solutions that address the other half. However, many organizations and users of NCCARE360 who are sending referrals on behalf of Latinx clients shared concerns, particularly from those who are undocumented, with entering personal information into a system that can be tracked for fear of legal repercussions. We take these concerns very seriously and have put several measures in place to address them.

One way we address these concerns is to support the decision for people to share as much or as little information as they are comfortable sharing, and we take measures to ensure to the best of our capability that they and their information are safe. We adhere to strict inclusion and exclusion criteria for all agencies that request to join our network and will not allow any agencies to join that will harm our communities. Another measure we have are workarounds to connect people to resources outside of our platform when they are not comfortable sharing personal information. This includes bringing in our partners at NC 211 who can connect people to all kinds of services and resources without recording personal information.

To continue addressing health inequities experienced by Latinx communities, NCCARE360 partners with many organizations that provide direct services to Latinx populations in North Carolina. Several of our partner organizations are vendors participating in the Community Health Worker (CHW) Initiative out of NCDHHS where CHWs can use NCCARE360 to refer people in their communities to needed resources. Some of our partners are recipients of our NCCARE360 Health Equity Grants! For example, the North Carolina  Justice Center serves as a Network Support Agency (NSA) and addresses immigration and refugee issues. El Centro Hispano also serves as an NSA and strengthens health equity in Latinx communities while CityGate Dream Center, a Community Organization Health Equity grantee, works to create a sense of belonging among Latinx folks in their community.

At the Dream Center, located in Burlington, NC, staff serve about 78% of Latinx communities, distributing food boxes and meals to families needing food assistance. Maria Hernandez, Resource Coordinator at the Dream Center said, “NCCARE360 has helped the Dream Center extend its reach in the community. Our goal has always been to create a sense of belonging in the community. One of the ways we do that is by centering the experiences of the Latinx community. The Latinx community can benefit from NCCARE360 because even if they have not come into our center, it doesn’t mean they can’t access our resources. We have been able to share resources with many Latinx families when they were referred to our center.” NCCARE360 is happy to be working with organizations like CityGate Dream Center to connect our Latinx communities to needed services and resources.

While the nation appoints an entire month to celebrate Hispanic/Latinx heritage, we will continue to celebrate the stories, values, and impacts of our Latinx neighbors all year long and we commit to attentively and thoroughly work with our partners and communities to reduce health inequities for our Latinx neighbors across the state. We hope you will join us!

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.

August 24, 2022
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Network Support Agencies Help Advance Health Equity in NC

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In 2019, North Carolina revolutionized coordinated care by launching NCCARE360, the first statewide network that electronically connects providers and community organizations together through a shared technology, allowing them to collaborate in addressing the social needs of their shared clients. Efforts to implement the program across the state soon ramped up, as the COVID-19 pandemic revealed the great number of North Carolinians who needed support in addressing social needs like housing, food, and transportation. By June 2020, NCCARE360 was active in all 100 counties in the state with almost 3,000 cases referred through the network. We were off to the races and excited about all of the connections being made in the platform that would result in better health outcomes in North Carolina.

With NCCARE360 fully implemented statewide, we work hard every day to continue growing the network. While it is robust and transformative, we know the technology is only as good as the network partners who are trained and empowered to use it to better serve their patients and clients. Our implementation partners regularly offer trainings and support, but almost as important as knowing how to use the technology is the capacity of organizations to respond to the referrals they receive. Organizations need plenty of people and resources to effectively answer the call and not being able to keep up with the demand is one of the most reported challenges among NCCARE360 users. Additionally, users wanted someone in their corner who could provide guidance and additional support when the going got tough.

To help organizations address these challenges, North Carolina Department of Health and Human Services (NCDHHS) and FHLI worked together to disburse funding from the CDC’s Coronavirus Response & Relief Supplemental Appropriations Act to local organizations dedicated to advancing health equity by tackling these social needs through their use of NCCARE360. This resulted in the NCCARE360 Community Organization and Network Support Agency Health Equity Grants.

These grants provided funding to community organizations to help increase their use of NCCARE360, to help them connect the people they serve to other community services, and to increase their own ability to respond to referrals. They also allowed FHLI to create a new role called Network Support Agencies (NSAs) for organizations to serve as local hubs and support clusters for community-based organizations currently on the NCCARE360 network, providing meaningful platform guidance and navigation. These grants work across healthcare and community organizations to create cross-sector partnerships to better address whole-person health.

NSAs are working diligently with organizations in their regions to increase their use of NCCARE360, recruit new organizations to join the network, and/or provide strategic planning and network navigation assistance to all platform users. They are also collaborating with large health systems in the region to assure there are resources available to patients who are discharged from hospitals. There are currently four NSAs working in the Triangle and Triad regions, preforming a plethora of activities to achieve grant goals such as providing direct NCCARE360 navigation which included instructions on sending and receiving referrals and workflow assistance, providing NCCARE360 overview information to various community organizations in multiple counties, performing outreach to various community organizations to encourage them to join NCCARE360, and creating monthly virtual town hall meetings to discuss NCCARE360.

By helping organizations boost their knowledge of NCCARE360 and increase their capacity to provide resources, NSAs are ensuring that more services are available to meet the social needs of our families and neighbors. At the end of the grant period, we aim to provide data demonstrating the impact of these funds in advancing health equity so that we may expand coverage to the western and eastern regions of the state where social needs are still prevalent. In the meantime, we will continue to grow the NCCARE360 network to better connect North Carolinians to the services they need to be healthy and well and to foster and strengthen sustainable partnerships between healthcare and community-based organizations to address overall health, not just healthcare.

To learn more about the health equity grants and recipients, visit our website at https://nccare360.org/community-funding/past-funding-opportunities/

December 1, 2021
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Darrell Deaton Joins FHLI and Will Oversee NCCARE360

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We are excited to announce the newest member of the NCCARE360 team, Darrell Deaton!

Darrell is joining us as the Vice President of NCCARE360 and has deep experience in the health space, particularly in North Carolina. He has extensive knowledge in establishing innovative joint ventures and business development initiatives with physician groups and health systems such as co-management agreements, clinical service joint ventures, and real estate ventures, and he has a career-long track record of leading teams to successful, quantifiable outcomes.

A North Carolina native from Winston-Salem, Darrell received his undergraduate degree in Economics and Psychology and his master’s degree in Health Administration both from Duke University. He began his career as a healthcare consultant focusing on strategic and facility planning before transitioning to the provider sector. Prior to joining FHLI, Darrell served for 25 years as the lead strategy executive for High Point Regional Health System and Vidant Health in North Carolina, Methodist Healthcare System in San Antonio, Texas, and SSM Health in St. Louis, Missouri. Darrell is also a senior examiner for the Malcolm Baldrige National Quality Award, a Fellow of the American College of Healthcare Executives, and a Meals on Wheels volunteer. 

As VP, Darrell will serve as the lead member of the NCCARE360 team and is responsible for driving the long-term goals and strategies for the program, including contracting and financial decisions related to the ongoing sustainability of the program, establishing evaluation criteria, launching and managing the NCCARE360 Community Advisory Board, and much more. 

Darrell started with FHLI and NCCARE360 on Monday, November 8, and said, “It is an honor and a privilege to join such a talented and devoted team at FHLI, where everyone is focused every day on improving the lives of all North Carolinians.” 

Darrell has a son, David, who lives in Winston-Salem and a daughter, Beth, who lives in Charlotte. Darrell currently lives in Greenville, NC, and plans to marry his fiancé, Sue Collier, in January. 

The NCCARE360 team is thrilled to have Darrell on board and look forward to continuing under his direction. We hope you will join us in welcoming Darrell to the NCCARE360 family. 

 

About NCCARE360
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, 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 2-1-1, Expound Decision Systems, and Unite Us.

Contact
For more information about NCCARE360, or any of its partner organizations, please send an email to connect@nccare360.org.

November 11, 2021
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NCCARE360 and NCServes Have Joined Forces to Provide More Resources for Military Members and Their Families

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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. It is also a good time to evaluate the many unique health and social needs this population experiences once they have removed the uniform.

During their service, military members are often at risk for various injuries and environmental hazards, and some experience new and lingering medical and mental health crises  when they return to civilian life. Unfortunately, in our often-fragmented health care system, many veterans find it difficult to access the care and resources they need when they are no longer active duty.

Approximately 200,000 service members leave active duty each year and are more likely than those on active duty to report health issues such as diabetes, smoking, heavy alcohol use, mental illness, post-traumatic stress disorder, and other chronic illnesses. These behaviors and conditions place veterans at greater risk for chronic diseases that are best managed by interdisciplinary teams.

With the 4th largest population of active-duty military and a large veteran population, it is critical that North Carolina has a strong network of resources for its military community. NCCARE360 is proud to have joined forces with NCServes in July 2021. This union will improve the experiences of North Carolina’s military community by increasing the number of services and resource available to our active-duty service members, veterans, and their families, and thereby making it easier to connect to services for medical care, mental health care, and resources for non-medical drivers of health like housing, food, and transportation.

Launched in 2015, NCServes was the nation’s first statewide coordinated network of public, private, and non-profit organizations working together to connect military service members, veterans, and military families with providers and resources for which they are eligible. NCCARE360 is the first statewide network that unites health care and human services organizations with a shared technology that enables providers to electronically connect those with identified needs to community resources and allow for feedback and follow up.

With this joining of forces, all NCServes network partners will now have access to the broader NCCARE360 network of community resources and additional NCCARE360 features and data to help them better serve military families. As part of the statewide network, this creates additional entry points for veterans seeking services. The common goal of improving health outcomes by addressing these frequently unmet needs demonstrates the natural fit of this union.

Together, NCCARE360 and NCServes will continue to provide a collaborative tool to help North Carolinians navigate a service system and connect them to the community resources they need most. We believe this unification honors North Carolina’s active-duty military, veterans, and their families by ensuring they have access to the resource and support they need.

 

About NCCARE360
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, 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 2-1-1, Expound Decision Systems, and Unite Us.

Contact
For more information about NCCARE360, or any of its partner organizations, please send an email to connect@nccare360.org.

September 13, 2021
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Community Health Workers (CHWs) are Utilizing NCCARE360

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When we think of health care, doctors and hospitals are likely the first thing to come to mind but health is affected by so much more than providers, clinics, or medication. Health is largely determined by our communities and all of the resources available—or unavailable—to us in these environments, as unmet non-medical social needs like food, housing, and transportation can cause negative health effects. For example, people who do not have access to grocery stores with healthy foods are less likely to have good nutrition, which raises their risk of health conditions like heart disease or diabetes. Positive health outcomes start in our communities. Who has the best knowledge of what communities need to achieve these positive outcomes than their own members? Fortunately, grassroot community health workers (CHWs) are leading the way.

CHWs are trained public health workers closing the gap between communities and health care systems. As trusted members of the communities they serve, CHWs provide critical services to those underserved and disproportionately impacted by public health threats, with one of the biggest threats right now being COVID-19. This trusting relationship allows CHWs to serve as a link between health and social services and the community in order to facilitate access to services and to improve the quality and cultural competence of service delivery. CHWs also “build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.” CHW activities include helping people complete applications to access health benefits, driving clients to medical appointments, or even providing health screenings. Now, NCCARE360 can support CHWs perform this important community health work.

NCCARE360 is the first statewide coordinated care network that helps providers electronically connect individuals with identified non-medical needs to community resources and allows for feedback and follow up. Now that NCDHHS has expanded the COVID-19 Community Health Worker program, bringing it statewide, CHWs are using NCCARE360 to make electronic referrals, communicate in real time, securely share client information, and track outcomes for our state’s most vulnerable populations.

This critical aid is happening all over North Carolina. At the beginning of August, Kinston, NC, achieved an above-average vaccination rate by making vaccine access a part of larger community-service efforts that utilized CHWs. NC COVID-19 vendors provided CHWs with tablets or laptops and mobile hotspots to leverage NCCARE360 and connect individuals and communities to traditional health care settings and organizations that address non-medical drivers of health.

CHWs are integral to connecting North Carolinians in underserved communities to medical and social supports. Since the CHW program started, more than 134,553 referrals have been made, connecting thousands of community members to needed services! The NCCARE360 implementation team is training and onboarding 350 additional CHWs to the NCCARE360 network this month so they can continue this critical work statewide.

If you have been impacted by COVID-19, or need help with vaccine support, please contact a CHW by reaching out to an organization in your county from this list.

 

About NCCARE360
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, 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 2-1-1, Expound Decision Systems, and Unite Us.

Contact
For more information about NCCARE360, or any of its partner organizations, please send an email to connect@nccare360.org.

December 2, 2019
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NCCARE360 Network Overview

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NCCARE360 is transforming care delivery in North Carolina. We recently spoke with a few key stakeholders about the network landscape, launch, and implementation progress. Watch our network video below to learn how partners across our state are working together to better connect health and human services providers and improve health for all North Carolinians.

“I see this as one of the most innovative and exciting things we’re doing in the state. I see it as a critical shared infrastructure for the state as we’re thinking about health transformation and we’re thinking about not just buying healthcare but buying health.” – Dr. Betsey Tilson, State Director and Chief Medical Officer, North Carolina Department of Health & Human Services

“We believe that health is owned and shaped by communities, and each community is uniquely different. NCCARE360 is designed to leverage the reality of people helping people and neighbors helping neighbors to improve health. NCCARE360 will also raise awareness to where resource gaps exist and hopefully help us all to fill those gaps. Health disparities will be narrowed, and we will be another step closer to achieving health equity.” – Anne Thomas, President and CEO, Foundation for Health Leadership & Innovation

Join NCCARE360 Today
September 23, 2019
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Trailblazing in North Carolina: A 6 Month Reflection

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Greetings!

My name is Jimmy Fisher and I am the State Director, NCCARE360/Unite Us. Together, our team has been working hand in hand with communities across the state to help empower their efforts to provide individuals with more opportunities to achieve a greater level of health.  We believe in NCCARE360 and know it will truly transform North Carolina!

When our team began working in Guilford, Alamance, and Rockingham in January 2019, we couldn’t have predicted how truly amazing these communities are. Fast forward six months and they have helped us build a well-established coordinated network with strong partnerships across various sectors, truly weaving together services.

It takes an immense amount of fortitude and bravery to be trailblazers, and the people of Guilford, Alamance, and Rockingham counties have led the way for the state of North Carolina as the first regions to launch with NCCARE360.

When you are surrounded by people that lean on each other and keep an individual at the center of care, amazing things can happen. Through NCCARE360, we have seen individuals facing difficult situations receive support within hours. We were able to successfully integrate NCCARE360 into Cone Health’s Electronic Health Record (EHR) system, EPIC. The integration provides Cone Health clinical staff with a seamless way to make referrals and receive closed loop information directly to and from their EHR. The NCCARE360 network in these three counties has grown with new partners joining each week, and we are excited to see expansion in the coming years.

In June, we hosted our launch party for Guilford, Alamance and Rockingham counties and it was a great celebration! In those counties, the network has grown from 60 organizations to over 120 in very little time. Statewide, we have now onboarded over 300 organizations, connecting more individuals to resources they need to live healthier. Our team is so excited about the organic connections at the local level, as well as weaving together historically siloed sectors.

Continuing this momentum will take all of us committing to the work. If you have not yet joined NCCARE360, we need you and are here to support your organization throughout the process. For more information, visit www.nccare360.org/join. Thank you!

Sincerely,
Jimmy

June 6, 2019
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Health Happens Locally – Welcome To NCCARE360 By Anne Thomas

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Together, we are changing the trajectory of health for all North Carolinians.

There is growing recognition that better coordination and investment in the non-medical drivers of health, like access to healthy food, safe and affordable housing and well-paying jobs, can improve health and decrease health care costs. Through NCCARE360’s groundbreaking, statewide coordinated network, health care and human services organizations are now united through a shared technology platform. NCCARE360 is a coordinated, community-oriented, person-centered approach for delivering care in North Carolina, and sets an example for the entire nation. In fact, this transformation is already underway in our state and rapidly expanding to support every person in North Carolina.

We have launched in 12 counties, with 9 counties in the implementation process. Over 1000 organizations have engaged in the socialization process and we look forward to working closely together.

NCCARE360 provides the infrastructure to connect all North Carolinians to community resources and has the potential to touch the lives and improve the health of all North Carolinians, including the commercially insured, Medicare, Medicaid, uninsured, military and veteran populations. NCCARE360 helps build a system of health that is focused on the person and helps them access the services and resources they need to be healthy. Together we’ve invested in both existing and new infrastructure to enable different types of organizations to connect people to health and social services in a way that makes the system more efficient. This provides visibility and accountability to help bridge the gap between health and social care.

Health happens locally, and NCCARE360 supports that important vision.

For more than 35 years, the Foundation for Health Leadership & Innovation has been developing programs and partnerships to improve health, and we are focused on addressing the needs of the whole-person through a whole community approach. We believe systems of care belong to and are shaped by the communities they serve. NCCARE360 will showcase the power of collaboration in our state as we work to ensure every partner delivering services in North Carolina is connected, knitting together our health care system and communities. Your support is instrumental in this process and we look forward to working together now and in the future!

Warmly,
Anne Thomas
President/CEO, Foundation for Health Leadership & Innovation