General

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/

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.

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