Community Care Partners -

For more information please email us at info@communitycarepartners.org For phone call inquiries please see Contact Us tab below.


PROGRAM OVERVIEW

The Community Care of North Carolina program (formerly known as Access II and III) is building community health networks organized and operated by community physicians, hospitals, health departments, and departments of social services. By establishing regional networks, the program is establishing the local systems that are needed to achieve long-term quality, cost, access and utilization objectives in the management of care for Medicaid recipients.

The program office is based in Raleigh at the North Carolina Office of Rural Health and Community Care, the office charged with administering the Community Care of North Carolina program (Access II and III). The 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. Additional grant funding has been obtained for start-up and for pilot demonstrations from Kate B. Reynolds Health Care Trust, the Commonwealth Fund, and the Center for Healthcare Strategies. The North Carolina Foundation for Advanced Health Programs, Inc. is a private non-profit organization that also serves to provide staffing and grant funding opportunities.


Community Care Partners of Northern Piedmont

Services Snap Shot

Community Care Partners of Northern Piedmont is one network under Community Care of North Carolina, the designated provider of care management services for Carolina Access ll Medicaid recipients. Community Care Partners provides services for Franklin, Granville, Person, Vance, and Warren County area. Our goal is to help recipients get the health care and support they need. We work in collaboration with primary care providers to ensure that recipients have access to all recommended care. We work with local agencies and the community to connect recipients with services that ensure a continuum of care.

Our support team includes:

  • Nurse Case Managers
  • Quality Improvement Coordinator
  • Community Health Workers
  • Housing Counselor
  • Registered Dietitian
  • Social Worker/Behavioral Health Coordinator
  • Health Check Coordinator
  • BSW:CC4C Care Manager/Breast feeding Peer Counselor/Home Health Social Worker
  • BSW: Social Worker Unit Supervisor/CC4C /Home Health Social Worker
  • OB Physician Champion
  • OB Nurse Coordinator
  • Healthy Access Plus Coordinator
  • Medication Assistance Coordinator

All of our services are FREE to recipients and include the following:

Disease Management

  • - Diabetes Congestive
  • - Heart Failure
  • - Sickle Cell
  • - Chronic Care
  • - Transitional/Chronic Care (from inpatient to home care)

Utilization Management

  • - Emergency Department use
  • - Hospital Inpatient stay
  • - Pharmacy Home (medication assessment and reconciliation)

Enhanced medical services for Aged, Blind and Disabled patients

Pregnancy Medical Home

  • - Population management to high-risk OB patients
  • - Improve quality of care/outcomes for mothers and babies

Palliative Care Initiative

  • - Advance directive for a natural death (living will)
  • - Health Care Power of attorney

Behavioral Health Coordination

  • - Integrated Mental Health Care
  • - Linkage to mental health services

Education (individual, group, health fairs)

  • - Pediatric and Adult Asthma Education
  • - Health Education
  • - Dental and vision resource Information

Nutrition Counseling (individual or group)

  • - Diabetes, Weight Management, Heart Disease,
  • - Cholesterol Management, or other health condition
  • - (referral required from the primary care doctor)

Health Check Coordination

  • - Ensure well child check-ups are current
  • - Ensure immunizations are current

Healthy Access Plus-Medication Assistance Program

  • - Franklin, Vance, Warren uninsured residents
  • - Pharmacy assistance
  • - Linkup to free clinic or reduced cost care

Healthy Access Plus-Community Care of NC Uninsured Parents (CCNC-UP) Pilot Program

  • - Limited Insurance benefits for uninsured parents of Health Choice recipients in Warren County only

Community Resources Linkage

  • - Transportation assistance information
  • - Monitoring supplies for self management
  • - Medical and social resources

 

Healthier Homes Initiative

This pilot program serves CAII Medicaid recipients in Vance, Warren, Franklin, Person, and Granville counties. The target group is 80% (Aged, Blind, Disabled, and children) and 20% (other chronically ill recipients). The initiative is expected to improve the health and safety of the targeted populations by assessment, education and subsequent implementation of home improvements. The improvements and education are specific to the individual health and safety needs of the recipient. Outside resources are leveraged to achieve needed improvements; Initiative grant funds may address specific needs of the recipient (example…portable window fans, allergy protective bed covers, and smoke detectors).



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