The people behind Community Care — and how we are improving health services in our state
A community-based infrastructure to target patients and populations in need
The processes and measurements behind our outcomes
Access to data to drive our success
Programs to anticipate and address specific patient needs
Management ToolsPatient Management Tools
Patient Management Tools
Materials to support providers and help educate patients
Link to CMMI homepage
For more information, go to the Medicare and Medicaid InnovationCMMI Site
Child Health Accountable Care Collaborative
Improving care for the state’s most vulnerable children
Community Care of North Carolina has received a three-year award from the Centers for Medicare and Medicaid Innovations Center (CMMI) to implement the “Child Health Accountable Care Collaborative” (CHACC). The program aims to improve care for children with complex medical conditions through close cooperation between North Carolina hospitals, primary care providers, and subspecialists.
In North Carolina, the five percent of children with special needs account for 53 percent of Medicaid’s child health expenditures. A significant number of these children with complex, chronic illnesses have been in a neonatal intensive care or pediatric intensive care unit and are at risk for readmission because of their fragile and complex medical state, technology dependence, and the potential for technology malfunction. Improving coordination of services provided to high-risk children is expected to lead to better outcomes, lower costs and improved patient experience.
Built on the medical home concept, Community Care of North Carolina matches each patient with a primary care provider who leads a health care team that addresses the patient’s individualized health needs. The Child Health Accountable Care Collaborative will leverage CCNC’s existing infrastructure and expand the scope of the Medical Home, improving co-management and shared responsibility between subspecialty providers and primary care providers.
CMMI grant funds will allow CCNC to embed children’s specialty care managers in hospitals and specialty clinics to work closely with pediatric subspecialists and primary care providers. Patient Coordinators will provide additional assistance to families navigating the complex medical services needed by these fragile children. These supports aim to promote more coordinated and effective use of health care services.
CHACC partners include:
- 14 CCNC local networks [link to CCNC network page]
- Five academic medical centers – Carolinas Medical Center (CMC), Duke University, Vidant Medical Center/East Carolina, University of North Carolina, and Wake Forest Baptist Medical Center
- Seven tertiary care hospitals – Cape Fear Valley Medical Center, CMC Northeast, Mission Hospital, Moses Cone, New Hanover Regional Medical Center, Presbyterian Medical Center, and WakeMed. [Question: include hot link to all the hospital partners?]
Key program components
- Enhanced Specialty Care Management – children's specialty care managers embedded in specialist clinics, academic medical centers and tertiary hospitals to provide care coordination and collaborate with pediatric subspecialists, primary care practices and other providers.
- Family-Centered Care and Connections to the Community –patient coordinators based in specialty clinics and hospitals to support parents and link patients to community-based services.
- Co-Management Process – a web-based communication system to facilitate collaboration between pediatric subspecialists and primary care physicians.
- Treatment and Co-Management Guidelines for high prevalence complex and chronic pediatric diseases.
The Child Health Accountable Care Collaborative is working to develop clinical pathways for key chronic illnesses. Please see the CHACC Guidelines page for more information.
For more information on the Innovations Grant program, please see the CMMI website.
CHACC is supported by Funding Opportunity Number CMS-1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.