The document describes North Carolina's program for care coordination of Medicaid recipients which includes assigning recipients to primary care medical homes, providing per member per month payments to support care management activities, and creating regional Community Care of North Carolina networks involving over 600 care managers to improve care delivery and reduce costs. It provides details on the various state agencies and organizations involved in coordinating care as well as the technologies and data used to support their efforts.

1. Care Coordination
Virginia Rural Health Association
Annual Conference
December 8, 2011
Chris Collins, MSW
Partnering for Healthy
Communities, since 1973
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2. • Provides comprehensive recruitment
assistance to communities and practices that
serve underserved residents since 1975
• Average placements per year over the past 6
ORHCC fiscal years (FYs): 149
2 OHRCC = Office of Rural Health and Community Care

3. • 20 yrs ago began assigning Medicaid Recipients to
a medical home
• Primary Care Providers responsible for medical
care coordination / 24 hour access
DMA • Currently 2,000 participating practices
PCP
DMA = Division of Medical Assistance
3 PCP = Primary Care Provider

4. Medicaid Supports Primary Care Providers
• Maintains a high fee for service payment of 95% of Medicare.
• Created regional networks that provide community health teams that
are a member of the primary care providers care team for high risk
recipients.
• Pays a pm/pm to cover the cost of care coordination
• Base payment of $1.00 for coverage and specialist coordination
• Increased to $2.50 when they join a regional CCNC network
• Increased to $5.00 when the recipient is Aged, Blind or Disabled
•Policy to strengthen the primary care infrastructure:
• Integrating behavioral health services
• Cover nutritional services for children
• Require targeted case managers to link with primary care
4 CCNC = Community Care of North Carolina

5. • 13 years ago began creating Community Care of North
Carolina (CCNC) Networks.
• Currently have 14 Regional Networks in all 100 counties.
• Every network provides community health teams with local
ORHCC / DMA care managers (600), pharmacists (26), psychiatrists (14)
and medical directors (20) to improve local health care
CCNC delivery
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6. The State identifies priorities and provides financial support through an
enhanced PMPM payment to community networks of $3.72 and $13.72
for the Aged Blind and Disabled.
• Nurse and social worker care management of high-risk patients
• Chronic Disease Management Initiatives (e.g. Asthma, Diabetes)
• Complex co-occurring chronic conditions
• Hospital Transition Care
• Emergency Department Utilization
• Pharmacy Initiatives
• Palliative Care
• Mental Health Integration / Chronic Pain
• Pregnancy Medical Home
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7. Care Management Activities:
• Risk Stratification/ Identify Target Population
• Screening/Assessment/Care Plan
• Medication Reconciliation, Polypharmacy & PolyPrescribing
• Referral / Linkage
• Self Management of Chronic Disease
Network Regional Activities:
• Enrollment/Outreach
• Population Health Management
• Quality Improvement Initiatives
• Clinical Leadership
• Integration of Physical and Mental Health
• Informatics Center
Centralized Statewide Activities:
• Advocacy
• Contract Negotiations
• Clinical Leadership
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• Informatics Center

8. • State web based Case Management Information System (CMIS)
• Health record, assessment, care plan, goals, measures and task
management, and secure communication
CMIS • Linked additional data sets to CMIS: claims, pharmacy, labs
• Informatics Center (IC)
• Linking additional data sources
• Analytics, Population Assessments, Risk Stratification,
IC Utilization Monitoring, Tracking of Care, Quality Measures,
and Key Performance Indicators.
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9. Quality:
Independently evaluated by AHEC auditors
• CCNC in the top 10 percent in US in HEDIS for diabetes, asthma,
heart disease compared to commercial managed care.
Cost savings/ Effectiveness:
Independently evaluated by the state and third-party consultants (Mercer
and Treo Solutions).
• More than $700 million in state Medicaid savings since 2006.
• Adjusting for severity, costs are 7 % lower than expected. Costs for
non-CCNC patients are higher than expected by 15 percent in 2008
and 16 percent in 2009.
• For the first three months of FY 2011, per member per month costs
are running 6 percent below FY 2009 figures.
• For FY 2011, Medicaid expenditures are running below forecast
and below prior year (over $500 million).
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10. • ORHCC
• Health Net:
• Medical Home
• Prescription Assistance
• Uninsured care coordinators using CMIS
ORHCC • Shadow claims
• Community Care of North Carolina for Uninsured Parents
(CCNC-UP) – State Health Access Program (SHAP) Grant
• DMA
• Moving Duals into CCNC
• Linking specialists to CCNC
• Health Check Coordination for Early Periodic Screening,
Diagnosis, and Treatment (EPSDT) using CMIS
DMA • Adding Children’s Health Insurance Program (CHIP)
recipients to CCNC
• Expanding with Health Home State Plan Amendment
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11. • Division of Public Health (DPH)
• Public health care coordinators using CMIS
(high risk pregnancy and at risk children)
• Data (immunization, vital records)
DPH • CDC Community Transformation Grant
• Division of Mental Health, Developmental Disability and Substance Abuse
Services (DMHDDSA).
• Agency for Healthcare Research and Quality (AHRQ) grant to integrate
facility and provider data on Medicaid and uninsured recipients into the IC
• SAMHSA Grant for Screening Brief Intervention Referral and Treatment
DMHDDSA (SBIRT) in Primary Care
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12. • CMS Multi Payer – Increases payment to the medical
home, adds care coordination benefits and provides
claims data in seven rural counties.
• Medicare
CMS • State Health Plan
MAPCP • Commercial Plan
• First In Health
• Employers
• Fund medical homes
• Wave primary care co-payments
Employers • Add care coordination benefits
13 MAPCP = (Medicare) Multi-Payer Advanced Primary Care Practice (Demonstration)

13. Surescripts Mental health
Pharmacy Clinical outcomes
Claims data Multi- Payer
Medicaid / Uninsured
Enrollment Claims data
646 / Multi-Payer*
Shadow claims
Medicare / Dual State Health Plan*
Medication Assistance State Facility Data
** Commercial*
ORHCC Uninsured
Immunizations
Chart Audits Vital Records
Enrollment
Public Health*
Claims CCNC
Lab
Real time Hospital
Informatics
(IP/ER) Center
Health
Medicaid Information
Exchange**
CHIP* and EHR*
*planning & implementation phase
14 IP = In-patient | ER = Emergency Room | EHR = Electronic Health Record
** discussion phase

14. CCNC
IC
Analytics & Care Management Pharmacy
Provider Information
Reporting Home
Portal System
Services Application
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15. CCNC
IC
Analytics & Reporting Provider Care Management Pharmacy Home
Services Portal Information System Application
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16. Empowering Networks and Providers to Deliver Coordinated Care
Direct access to IC software
CCNC / Health Net Providers CMIS users
CCNC (Medicaid / HealthNet) Networks CCNC Medicaid (600)
Mental Health Networks (LME) Health Net Uninsured (50)
Local Health Departments Public Health (500)
Local Hospitals
State Facilities
17 LME = Local Management Entity

17. Chris Collins, Deputy Director
NC Office of Rural Health and Community Care
2009 Mail Service Center
Raleigh, NC 27699-2009
Telephone: (919) 733-2040
Email: chris.collins@dhhs.nc.gov
Website: www.ncdhhs.gov/orhcc/
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