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About
UsAbout UsAbout Us
The people behind Community Care — and how we are improving health services in our state
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Our
NetworksOur NetworksOur Networks
A community-based infrastructure to target patients and populations in need
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Quality
Improvement -
Informatics
Center- Informatics Center Overview
- North Carolina Community Health Information Portal
- Provider Portal
- IC Report Site
- Case Management Information System
- Pharmacy Home
- North Carolina Health Information Exchange
- Medication Access and Review Program (MARP)
Informatics Center
Access to data to drive our success
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Population
Management -
Emerging
Initiatives- Beacon Community
- Care Coordination for Children (CC4C)
- CCNC Adult Care Home Workgroup
- Child Health Accountable Care Collaborative
- Clinical Integrity
- Dual-Eligible Initiative
- Medicare Quality Demonstration (646 Waiver)
- Multi-Payer Demonstration
Emerging Initiatives
New demonstrations, pilots and programs
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Patient
Management ToolsPatient Management ToolsPatient Management Tools
Materials to support providers and help educate patients
Population-based Management
The big picture plus a focus on individual patients
CCNC emphasizes population-based health management and quality improvement initiatives. CCNC networks are responsible for the delivery of care management services to selected patients that will improve quality of care while containing costs.
Although each network will develop its care management department based on knowledge of local resources and stake holders, the care coordination core processes are the same between networks. To assure consistency across networks, a "Standardized Care Management Plan" has been developed. The plan consists of a set of guidelines and standards for care management activities and reporting.
In summary, the plan provides for:
- Population Stratification, Case Identification, and Member Assignment -- The application of a common series of criteria and measures to the enrolled population to describe the distribution and severity of illness, and the index of resource utilization; assigning members to certain risk strata for care management, disease management and other preventive health programs.
- Member Care Coordination -- The provision of structured interventions to targeted groups in order to ameliorate bio-psycho-social risk factors and provide ongoing monitoring of the effectiveness of the care coordination effort.
Details on specific population management programs can be downloaded at right.