SummaryA state-based, public-private partnership known as Community Care of North Carolina supports medical homes in managing the health of Medicaid managed-care enrollees by fostering the development of local, self-governing community health networks that provide care/disease management services and participate in statewide and local quality improvement initiatives. The state supports these networks and physicians through separate per-member, per-month payments, whereas Community Care of North Carolina provides support through the provision of various resources, including a system that facilitates the exchange and management of clinical information. Various studies have found that the program improved the quality of care for those with asthma and diabetes and significantly reduced hospital and emergency department use and health care costs, yielding savings of nearly $150 million in 2007 alone.Moderate: The evidence consists of before-and-after comparisons as well as nonrandomized comparisons of program participants to similar individuals not enrolled in the program. Key outcomes measures include asthma and diabetes care measures, utilization, and costs of care.
Developing OrganizationsCommunity Care of North Carolina
Date First Implemented1998
In July 1998, Community Care of North Carolina was piloted in nine counties. Wake County and Johnston County, adjacent counties located in the middle of the state, began participating in 2003. As of 2009, all counties in the state participate in the program.
Insurance Status > Medicaid
Problem AddressedMany states have supported the development of medical homes for Medicaid beneficiaries, but most have not yet created systems to support these medical homes in providing coordinated care for large populations, which is critical for the many Medicaid beneficiaries with chronic disease(s).
- Little support for population-based care: Although primary care providers working alone can provide effective care to individual Medicaid patients via a medical home model, these providers often do not have the tools or support needed to execute a coordinated approach to managing the health of the entire population of Medicaid enrollees they serve.1
- A need for chronic disease management: A population management approach is critical to the care of Medicaid beneficiaries, who often experience chronic diseases such as asthma, diabetes, and chronic obstructive pulmonary disease. For example, in 1998 (the year Community Care of North Carolina was implemented), approximately 14 percent of North Carolina's Medicaid population had asthma; asthma-related care cost the state more than $23 million that year, with asthma being the number-one reason for hospitalizations and emergency department (ED) visits among Medicaid beneficiaries younger than 21 years.2 More recent statistics suggest that the prevalence of chronic disease remains high among Medicaid beneficiaries; a Behavioral Risk Factor Surveillance System Survey found that 11.1 percent of adult Medicaid beneficiaries in North Carolina had diabetes in 2008, whereas 22.9 percent had asthma (either at that time or at some point in their lives).3
Description of the Innovative ActivityA state-based, public-private partnership known as Community Care of North Carolina supports medical homes in managing the health of Medicaid managed-care enrollees by fostering the development of local, self-governing community health networks that provide care/disease management services and participate in statewide and local quality improvement initiatives. The state supports these networks and providers through separate per-member, per month (PMPM) payments, whereas Community Care of North Carolina provides support through the provision of various resources, including a system that facilitates the exchange and management of clinical information. Key elements of the program include the following:
- Local community health networks: Local, self-governing community health networks provide care to enrolled beneficiaries. Networks are composed of community providers, hospitals, health departments, and departments of social services. Networks are structured either as a newly created, not-for-profit organization or are formed within an existing governmental or private nonprofit organization (e.g., the health department or local public hospital). Each network has a governing board or steering committee to oversee the strategic and administrative aspects of network activities and a Medical Management Committee, chaired by a clinical director, that addresses implementation of best clinical practices, disease management, and quality improvement initiatives. Participating providers contract with the state to care for Medicaid enrollees and then contract separately with the network to participate in the Community Care of North Carolina program. Medicaid enrollees select a contracted primary care provider to serve as a medical home.
- Disease management/quality improvement initiatives: Each network implements disease management and other quality improvement initiatives mandated and supported by Community Care of North Carolina; network-specific initiatives are also developed in response to the specific care needs of the enrolled population. As part of these initiatives, the networks collaborate with other agencies (e.g., the local mental health agency and the local health department) in providing or coordinating services. The State Medicaid program pays the networks and participating providers a separate PMPM fee to support these services and programs (see the Funding Sources section for more details).
- Statewide initiatives: Every network must participate in Community Care of North Carolina's standardized core initiatives related to quality improvement or cost containment. The clinical directors from each network meet regularly to design these initiatives, determine performance measures, and create monitoring and evaluation processes. All networks implement the following quality improvement initiatives: asthma, diabetes, chronic obstructive pulmonary disease, hypertension, and heart failure disease management programs; palliative care; integration of physical health and mental health; pharmacy management; ED management (to reduce inappropriate utilization); transitional support; and care management of high-cost, high-risk patients. (Details about each of these initiatives can be found on the Community Care of North Carolina Web site.)
- Network-specific initiatives: Individual network initiatives vary. For example, the Wake/Johnston county network initiatives also include programs on pediatric obesity prevention, improving the cultural and linguistic capacity of providers who care for non–English-speaking patients, chronic pain management, and facilitating home environmental assessments for patients with asthma.
- Care management: Care management ensures that each Medicaid patient receives care based on his or her own needs, within the context of the disease management initiatives described above. In addition, the care managers support the medical homes in population management activities.
- Care manager logistics: Care managers hired by the networks are either dedicated to larger practices/clinics or shared by several smaller practices. In Wake and Johnston Counties, care managers are embedded in a Federally Qualified Health Center and a health department. Both are large safety net providers that serve a large percentage of each county's Medicaid population.
- Care manager duties: Care managers provide patient education and care coordination services at the point of care, with specific responsibilities that vary depending on community or provider needs. Typically, care managers help identify patients with high-risk conditions or needs, assist providers in providing disease management education and followup, help patients coordinate their care and access needed services, make referrals to consultant pharmacists and to community-based services, gather and provide to providers discharge summaries and medication reconciliation forms to help transition recently discharged inpatients to outpatient care, and collect data on process and outcome measures. The care manager typically has access to electronic or paper charts so that he or she can provide feedback regarding potential gaps in care and ensure that the network's care quality measures are addressed.
- Clinical information support: Community Care of North Carolina identifies and distributes educational resources and tools to the networks to facilitate population-based care. In addition, providers and care managers use Community Care of North Carolina's secure, Web-based Care Management Information System for enrollee care management. This system includes a claims/clinical data repository, secure messaging, a module to produce clinical reports (both individual and population level), care assignment function, a patient assessment and care planning module, and care manager task list management services. Community Care of Wake and Johnston Counties uses the system to identify the highest-risk, highest-cost enrollees and to ensure that care management services are provided to these patients. Patients are divided into clinical risk groups, which allows the network to identify outliers to target services. In addition, Community Care of North Carolina staff members access the Care Management Information System along with claims data to identify gaps in patient care; real-time data (e.g., on patient admission or presentation to the ED) can also be shared proactively with participating practices. Information provided in March 2012 indicates that the Informatics Center is another claims-driven Web-based tool that allows the network and participating practices to obtain network-level, practice-level, and patient-level data.
- Expansion to obstetrical care: Information provided in March 2012 indicates that expansion of program activities to include obstetricians began in 2011 with the Pregnancy Medical Home Initiative and represents a robust partnership between Community Care of North Carolina and North Carolina Public Health. Obstetric practices contract with local Community Care of North Carolina networks to become pregnancy medical homes and receive network support. High risk women, identified at the practices, are referred to care management via the local health departments. Financial incentives for the practices include payments for completing the high-risk screen and postpartum visits and increased reimbursement for vaginal births, thus achieving par with the Cesarean-section reimbursement rate.
Context of the InnovationCommunity Care of North Carolina, initially based in the state's Office of Rural Health and Community Care, is a managed care option that serves more than 1.2 million recipients. Fourteen community health networks of providers, hospitals, health departments, and departments of social services cover all of North Carolina's 100 counties; networks include approximately 1,500 medical homes and almost 4,500 providers. The North Carolina Office of Rural Health started exploring the medical home model in 1991 by creating the Primary Care Case Management Program, which allowed the State Medicaid program to partner directly with clinicians providing care to beneficiaries. By the mid-1990s, 99 out of 100 counties participated in this program, allowing Medicaid beneficiaries in certain categories of medical eligibility to have a medical home. Recognizing the need to support these medical homes in population management, State representatives developed Community Care of North Carolina. For example, Wake County and Johnston County are located in the middle of North Carolina and comprise one Community Care network; Wake County serves a largely urban population, whereas Johnston County is a largely rural area. Community Care of North Carolina enrolls approximately 96,000 Medicaid beneficiaries in these 2 counties, representing roughly 64 percent of the counties' total Medicaid population. As of April 2011, Community Care is no longer under the Office of Rural Health.
ResultsVarious studies have found that the Community Care of North Carolina program improved the quality of care for those with asthma and diabetes and significantly reduced utilization and health care costs, yielding savings of nearly $150 million in 2007 alone.
Moderate: The evidence consists of before-and-after comparisons as well as nonrandomized comparisons of program participants to similar individuals not enrolled in the program. Key outcomes measures include asthma and diabetes care measures, utilization, and costs of care.
- Lower utilization/costs and better care for patients with asthma4: A 2001 study found that Community Care of North Carolina enrollees younger than 21 years had a 34-percent lower hospital admission rate and an 8-percent lower ED visit rate than did similar patients in a control group. In addition, the average cost per episode for children enrolled in Community Care of North Carolina was 24-percent lower than those not enrolled ($687 vs. $853). In the spring of 2004, an independent chart audit found a 21-percent increase in the number of patients with asthma who had been staged and a 112-percent increase in the number of asthma patients who received influenza vaccines.
- Better care for patients with diabetes: Randomized chart audits comparing baseline (2000) to 2004 statistics found that the program improved diabetes care, including a 10-percent increase in referrals for dilated eye examinations, a 62-percent increase in influenza vaccines, an 18-percent increase in foot examinations, an 11-percent increase in lipid testing, and an 8-percent increase in blood pressure testing.4
- Significant cost savings: Mercer Human Resources Consulting Group (Mercer) estimated that Community Care of North Carolina saved approximately $60 million in fiscal year 2003, $124 million in fiscal year 2004, $231 million in fiscal years 2005 and 2006 combined, and $135 to $149 million in fiscal year 2007.5 These savings are the result of many different initiatives. For example:
- Asthma and diabetes disease management: An external evaluation estimated a $3.5 million savings due to the asthma management program and a $2.1 million savings due to the diabetes management program.6
- Better medication management: Mercer's analysis of the cost-effectiveness of over-the-counter and prescription medication coverage estimated nearly $1 million in savings during the first 2 quarters of fiscal year 2005.5 In 2004, the Prescription Advantage List resulted in an estimated $9 million in cost savings, and the program to reduce nursing home polypharmacy resulted in $1.7 million in cost savings.4
- Updated cost savings estimates: Information provided in March 2012 indicates that a December 2011 analysis by Milliman, Inc., a national consulting firm based in California, found that Community Care of North Carolina saved the state of North Carolina nearly $1 billion in health care costs over the 4-year period from fiscal year 2007 through fiscal year 2010. An analysis by health care analytics consultant Treo Solutions, Inc. found that the organization saved nearly $1.5 billion in health care costs from 2007 through 2009.
Planning and Development ProcessKey elements in the planning and development process included the following:
- Soliciting primary care provider involvement: In the mid-1990s, State representatives met with primary care providers participating in the Primary Care Case Management program to solicit feedback regarding the kind of support they needed to better manage their Medicaid patient populations. In 1997, these representatives sent a request for proposals to all medical homes with 2,000 or more Medicaid members, which generated strong interest among many practices in piloting the program.
- Pilot testing: In 1998, Community Care of North Carolina was piloted in nine counties. Providers in these counties created a community health network of local health partners and set up a governance structure for the network. Clinical directors selected quality improvement initiatives (beginning first with asthma disease management) and designed performance measures to gauge the program's impact.
- Ongoing program development: Community Care of North Carolina supportive services were developed over several years as pilot networks provided feedback regarding how the state could better support them.
- Recruiting and training care managers: Networks recruited care managers; disease-specific training and education occurs on an ongoing basis via inservice sessions sponsored by Community Care of North Carolina. In addition, many care managers have completed a care management certification program.
- Expanding statewide: The program expanded to include 14 networks covering all 100 counties in North Carolina.
- Transitioning to a more holistic approach: The care management program has transitioned away from disease-specific initiatives to a more holistic approach for each patient. The focus is managing the highest risk population with chronic conditions and physical and behavioral comorbidities, transitional care patients, and other select groups. To support the behavioral health integration with the medical homes, psychiatrists were added to the networks.
Resources Used and Skills Needed
- Staffing: There is no "typical" staffing pattern at participating practices. Teams generally include a physician, nurse, and medical assistant; some teams also include a behavioral health specialist, mental health therapist, or pharmacist. Care managers (nurses, social workers, or behavioral health workers) are embedded in practices with a large number of program enrollees. Information provided in March 2012 indicates that Wake and Johnston Counties collectively employ 25 nurse care managers, 5 social workers, 2 pharmacists, 1 dietitian, 3 program leaders/managers, 2 administrative staff members, 3 information technology staff members, and 5 practice liaisons. Care managers typically handle roughly 2,500 patients; this translates into an active caseload of approximately 75 to 100 enrollees who need ongoing management at a medium to high "touch" level.
- Costs: Data on program costs are unavailable; the primary costs consist of salary and benefits for care managers and other network-level staff. Practice-related costs are covered by PMPM payments received from the state (see Funding Sources section for details).
Funding SourcesNorth Carolina Medicaid Program
The Community Care of North Carolina Program Office is sponsored by the Office of the Secretary, the Division of Medical Assistance (the state's Medicaid agency), and the North Carolina Foundation for Advanced Health Programs, Inc. Initially, each network received a $25,000 grant from the Kate B. Reynolds Health Care Trust for network infrastructure development and staffing. The program has received additional grant funding for specific initiatives from private organizations, including the Kate B. Reynolds Health Care Trust, the Commonwealth Fund, the Center for Healthcare Strategies, and the North Carolina Foundation for Advanced Health Programs, Inc.
Networks and primary care providers also receive PMPM funding from the state, as outlined below:
- Network funding: Network fees cover the costs of hiring program staff (e.g., program director, care managers, consultant pharmacists) and implementing disease management programs and other quality initiatives. Information received in March 2012 indicates that each network receives $3 PMPM for a regular Medicaid patient and $13 PMPM for aged, blind, and disabled patients; a portion of the PMPM payment for the aged, blind, and disabled is returned to the central office to support administrative and clinical leadership and all the functionalities available through the centralized informatics center.
- Physician funding: In addition to fee-for-service reimbursement for the provision of care, providers receive an additional $2.50 PMPM for a regular Carolina Access Medicaid patient and $5 PMPM for aged, blind, and disabled Carolina Access Medicaid patients to cover the cost of medical home and disease management services.
Tools and Other ResourcesCommunity Care of North Carolina patient management tools are available on a wide variety of topics related to cardiovascular diseases, diabetes, asthma and other respiratory conditions, skin conditions, gastrointestinal conditions, infectious diseases, mental health, musculoskeletal diseases, men's health, women's health, neurological conditions, cancer, kidney disease, preventive care, and geriatric care. These tools are available at: http://www.communitycarenc.org/.
The Community Care of North Carolina Program Office suggests Best Practices in Coordinated Care, published by Mathematica Policy Research, as a reference for describing the key processes involved in the delivery of care and disease management services. This paper is available at: http://www.mathematica-mpr.com.
Getting Started with This Innovation
- Enlist local leader support: Having local providers lead the program is critical to convincing other providers to adopt it.
- Consider appropriate State agency to house program: Medicaid agencies often take a regulatory, bureaucratic approach to partnerships. In North Carolina, the State Office of Rural Health has always been focused on community development; therefore, this agency was a natural choice to build the program.
- Establish links to community programs: Identify resources already being offered by community groups (rather than "reinventing the wheel"), and partner with these groups to ensure continuity of care.
- Start with "easy" care components: Community Care of North Carolina began by developing an initiative to improve asthma care for pediatric populations, in which relatively straightforward, proven interventions exist. Early successes built support and enthusiasm, enabling the program to expand to more complicated populations and diseases.
- Consider investments in community-wide information systems: Many counties lack health information technology, with most providers still relying on fax machines for communication. As a result, Community Care of North Carolina invested a significant amount of time and grant funding to build the Care Management Information System with data exchange capabilities to support local providers.
- Position care transition support as a good way to build relationships: Care managers can improve care and serve providers by facilitating discharge planning, performing medication reconciliation, and providing other tasks designed to ensure smooth patient transitions between care settings. Community Care of North Carolina made a concerted effort to highlight these benefits to gain the support of the State hospital association, the family practice professional association, the pediatric professional association, and other players critical to the provision of high-quality care.
Sustaining This Innovation
- Expect adoption to be more difficult as program expands: Early adopters (e.g., those in the pilot counties) are likely to be enthusiastic and innovative, but engaging late adopters may prove more difficult.
- Continue reaching out to providers: Ongoing efforts are needed to engage providers in using network services, including care management.
Contact the InnovatorProgram office contact:
Jennifer Cockerham, RN, BSN, CDE
Director, Chronic Care Program and Quality Management
Susan L. Davis, RN, MPH, CCM
Executive Director, Community Care of Wake and Johnston Counties
Innovator DisclosuresMs. Cockerham and Ms. Davis have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesCommunity Care of North Carolina Wake/Johnson County program. Available at: http://www.ccwjc.com.
Community Care of North Carolina Disease and Care Management Issues. 2007 CCNC Update. Available at: https://www.communitycarenc.org/our-results/.
McCarthy D, Mueller K. Community Care of North Carolina: building community systems of care through state and local partnerships. The Commonwealth Fund. 2009 June. Available at: http://www.commonwealthfund.org/Content/Publications/Case-Studies/2009/Jun/Community-Care-of-North-Carolina--Building-Community-Systems-of-Care-Through-State-and-Local-Partner.aspx.
Original publication: May 08, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: September 25, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: March 20, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.