March is National Social Work Month, a time to recognize and celebrate the important role social workers play in supporting individuals, families, and communities. Social workers are professionals who are trained to help people overcome challenges and improve their well-being through a wide range of services, including counseling, case management, advocacy, and community outreach.
Social workers often find it challenging to connect their clients with the right resources and services to address their needs. They are frequently assisting clients with complex cases who require support from multiple providers and organizations. Fragmented systems make it difficult to navigate the complex network of community resources and services that are available. Fortunately, NCCARE360 is making it easier to send referrals for community resources and collaborate with other providers. Social workers can use the platform to quickly and easily refer clients to a wide range of services and resources, including housing assistance, food pantries, transportation services, mental health services, and more.
Because NCCARE360 has the ability to track referrals and outcomes, social workers can monitor the status of their referrals and see if their clients successfully accessed resources, helping to ensure their clients are receiving the support they need to improve their health and well-being. In addition to making referrals to community resources, NCCARE360 also facilitates communication and collaboration among providers. Social workers can use the platform to communicate with other providers and share information about their clients’ needs and progress. This can help ensure that all members of a client’s care team are working together to provide the best possible support.
This month, we are highlighting Leslie Craver, an incredible social worker who utilizes the NCCARE360 network daily to connect their clients to needed social supports and services.
Leslie Craver is a part-time Family Caregiver Specialist at The Life Center of Davidson County, an organization that provides high quality daytime care to older and impaired adults in Lexington, NC. Her interest in social work began in college and led her to a 30-year career with NC Department of Social Services, where she worked mainly in adult services. As a Home Adult Specialist, she monitored adult care homes and investigated any issues that arose in adult care. When it came time to retire, joining The Life Center was a natural fit for Leslie. At the same time, The Life Center was awarded a health equity grant from FHLI to increase their utilization of NCCARE360. Leslie trained on the platform and now uses NCARE360 to connect their residents to needed resources.
“I spent a lot of my time in DSS linking people to resources, so it wasn’t a big jump for me, just a different platform to do so.“ -Leslie Craver.
Leslie states NCCARE360 has helped expand her knowledge of resources not just in Davidson County but throughout the state, and she believes the next important step is helping other community organizations like The Life Center understand the value of the NCCARE360 program so they will be just as eager to join the network. “When you have multiple people come and go from different agencies, it’s a useful tool to not have to make a lot of phone calls. You can just look in the system and see all the places they’ve been and if they got help or not,” she said.
Not only does Leslie use NCCARE360 to connect The Life Center’s clients to resources, but she also makes visits to elderly people in the community who are unable to leave their homes and to the caregivers of those who cannot be left alone. She reaches out with food vouchers, PPE bags and other needed items, and she’s even provided some shopping for elder community members using those food vouchers. Then she enters those services in NCCARE360 and provides additional assessments for any other unmet needs that she can assist with.
“The Life Center is the best,” Leslie declared. “They do great work and tried to reach out even before NCCARE360, and this is just another way they are working to expand.”
National Social Work Month is an opportunity to recognize the important work that social workers do to support our communities. NCCARE360 is a useful tool that is helping them make referrals to community resources and collaborate with other providers to address the complex needs of their clients. By leveraging technology and working together, social workers can help ensure that everyone has access to the resources they need to thrive. NCCARE360 is grateful for the hard work and dedication of all social workers who help improve our communities.
NCCARE360 is the first statewide social needs referral platform in the country coordinating referrals for more than 100,000 North Carolinians to needed services since its creation in 2019
Cary, North Carolina – NCCARE360, the first statewide coordinated care network in the country that better connects people to local services and resources has reached a new milestone with more than 100,000 people in North Carolina being referred for services through the platform since its implementation in 2019.
NCCARE360 is the first statewide network that unites health care and human services organizations, assesses for and identifies unmet social needs, and enables a coordinated, person-centered approach for delivering care in North Carolina. NCCARE360 is the result of a strong partnership between the NC Department of Health and Human Services (NCDHHS) and the Foundation for Health Leadership & Innovation (FHLI). The NCCARE360 implementation team includes United Way of NC, NC 211, Unite Us, and Expound Decision Systems.
The referral for the 100,000th person was part of the rollout of the Healthy Opportunities Pilots, the nation’s first comprehensive program to pay for non-medical services, such as food and housing, for Medicaid enrollees. A community-based nonprofit providing inspections for housing safety and quality was able to provide high-priority repairs for home accessibility and safety modifications from a referral made securely through the platform.
In May 2019, one of the first referrals through the NCCARE360 Platform powered by Unite Us resulted in an individual finding employment assistance. For NCCARE360’s 1,000th referral, a Piedmont resident was referred to social services by a local health department’s WIC & Nutrition services and was able to receive help with diapers, bedding, and other necessities for their home.
“To be healthy, it is essential to have access not only to medical care but also to non-medical drivers of health like food and housing”, said Dr Elizabeth Cuervo Tilson, State Health Director and Chief Medical Officer for NCDHHS. “NCCARE360, a shared infrastructure across the state, continues to be a critical tool that improves coordination and enables a focus on whole person health.”
Platform trends show that as of November 30, 2022, the top five service needs by volume statewide were food assistance, housing and shelter support, individual and family support (e.g., childcare assistance), income support (e.g., emergency/one-time financial assistance), and utility bill payment assistance.
In addition to serving more than 100,000 people statewide, the NCCARE360 team continues to grow and support the network —especially in rural and under-resourced areas—to increase the capacity and efficiency of communities to respond to referrals. The NCCARE360 network has now surpassed 3000 organizations onboarded onto the platform and 7,500 active programs to which referrals can be made. With almost 50,000 network users actively sending and receiving referrals, almost 80% of accepted referrals are accepted in 4 days or less. 92% of referrals made as part of the Healthy Opportunity Pilots were accepted in fewer than 3 days.
“The purpose of NCCARE360 is to improve the health and well-being of all North Carolinians by recognizing there are many aspects that affect our health,” said David Reese, President and CEO of Foundation for Health Leadership & Innovation. “Today’s announcement is an important step in achieving this purpose.”
Organizations interested in joining NCCARE360 as a network partner can visit www.nccare360.org for more information. People who are interested in making a connection through NCCARE360 can visit https://nccare360.org/resources/ to request assistance.
This Veterans Day, NCCARE360 is highlighting one of our respected network partners working with veterans and their families: Veterans Bridge Home.
Each year, Veterans Day offers an opportunity for Americans to honor all military service members who have served our country. It’s a day to recognize and give thanks for their courage, determination, and loyal service to the United States. With North Carolina being home to 12 military installations and over 730,000 veterans, NCCARE360 proudly joined forces with NCServes in July 2021 to ensure our state has a strong network of resources for its military and veteran community. NCServes is the country’s first coordinated system of public, private, and nonprofit organizations working together to provide support to military members and their families, and is used by many veterans-serving agencies, like Veterans Bridge Home, to coordinate health care and human services for this population.
We know that approximately 200,000 service members leave active duty each year and veterans are more likely to report health issues such as diabetes, smoking, heavy alcohol use, mental illness, post-traumatic stress disorder, and other chronic illnesses than those on active duty. These behaviors and conditions place veterans at greater risk for chronic diseases that are best managed by interdisciplinary teams. In North Carolina, the top service needs experienced by the veteran population include housing and shelter needs, employment and financial assistance, benefits navigation, and food assistance. Veterans Bridge Home is one organization working to link veterans and their families to the community and to resources that address these social needs.
Veterans Bridge Home serves as an entry point for veterans who don’t know where to turn to access support and services. They connect veterans and their families to the community through their network of partners and help them navigate needs like employment, create social connections, and settle their families by connecting them to the resources they need to be successful and thriving leaders in our community. Paul Berry served in the United States Marine Corps for 30 years, retiring as a Command Sergeant Major, and has been the Regional Network Director at Veterans Bridge Home for the past two years. He has been doing this type of work for more than half a decade. He highlighted some of the major ways that NCCARE360 has positively impacted the work of Veterans Bridge Home, which in turn helps to improve the health and wellbeing of our veteran population.
NCCARE360 helps assess for and identify unmet social needs through embedded screening questions built right into the platform. The screener assists network organizations in understanding what resources a person may be eligible for so they can make the best referral possible. Prior to the creation of NCServes and NCCARE360 organizations often tended to address one need at a time. For example, if a veteran presented with a request for housing, the organizations would tackle that need without questioning other potential needs. However, NCServes quickly realized that these veterans were returning because only one part of their need had been addressed—housing—when they also had transportation and food needs. Thanks to the screeners, coordinators at Veterans Bridge Home are now able to get veterans to the right services or resources, ensuring that whole-person health and well-being is addressed.
Paul also explained that unification with NCCARE360 has allowed Veterans Bridge Home to begin addressing family needs, as well. The NCCARE360 Network includes Resource Navigators supported by NC 211 who can support complex referrals and stay with a client through the referral process if needed. Veterans Bridge Home can now refer veterans’ partners, children, and other family members with identified social needs to the NCCARE360 Navigators who can connect them with services and resources available to civilians. Before unification, they were only able to refer clients to military resources.
“Yes, we work with that specific population of veterans and we’re proud of that, but we also know that if there are other stressors in that home, we want to be part of that solution and the NCCARE360 Navigators and NC 211 have been great partners in addressing those needs,” – Paul Berry, Regional Network Director, Veterans Bridge Home.
Another unexpected yet welcome benefit to joining the NCCARE360 Network has been an increase in funding opportunities. Through their partnership with NCCARE360, Veterans Bridge Home has been able to apply for and receive two new grants. They are the recipients of the NCCARE360 Health Equity Grants that were funded through the CDC’s COVID-19 Health Disparities Initiatives grant, which they are using to fund staff members, operational expenses, and event costs. They are also one of only two coordination centers to receive the Staff Sergeant Parker Gordon Fox Suicide Prevention Grant, which is their largest grant to date. This additional funding will allow them to continue to grow their capacity to better serve more veterans and their families.
Plugging into the NCCARE360 Network meant Veterans Bridge Home has also connected with other community organizations in the network, growing their partnerships and civic relationships. Paul found that the top 10 organizations sending referrals to Veterans Bridge Home has changed since joining the network, where many of the senders are no longer veteran-only serving organizations, but rather those that serve communities at large. Building relationships with these agencies helped change the playing field and allowed Veterans Bridge Home to embrace the no-wrong-door approach to care coordination. Now, if they receive referrals for non-veterans, they know they can refer them to an organization in the NCCARE360 Network or even to the NCCARE360 Navigators; they’re happy to use the opportunity to make their community partners aware of the federal money available for veterans that frees up local or state funding for civilians, helping to guarantee the best use of resources. Paul attributes this success to capabilities of the NCCARE360 network and technology.
Veterans Bridge Home is a staple among the military community, providing veterans and their families an opportunity to better navigate their unique social needs. They are also creating social connections to the communities and resources veterans need to be successful, healthy, and whole. This Veterans Day and every day, NCCARE360 is proud of the impact Veterans Bridge Home is making and we are honored to have them as a network partner.
Be sure to visit their website to learn more about their work and how you can help support NC’s veteran population and their families.
About NCCARE360 NCCARE360 is the first statewide network that unites health care and human services organizations with a shared technology that assesses for and identifies unmet social needs, and enables a coordinated, community-oriented, person-centered approach for delivering care in North Carolina. NCCARE360 is the result of a strong public-private partnership between the NC Department of Health and Human Services (NCDHHS) and the Foundation for Health Leadership & Innovation (FHLI). The NCCARE360 implementation team includes United Way of NC, NC 211, Unite Us, and Expound Decision Systems.
Contact For more information about NCCARE360, or any of its partner organizations, please send an email to connect@nccare360.org.
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!
