Pediatric Enhanced Care Program
The Pediatric Enhanced Care Program (PECP) in Brenner’s Children’s Hospital is a Healthy Tomorrows Partnership for Children Program (HTPCP) which provides family- centered, community based care coordination for families of children with complex health care needs. Savithri Nageswaran, MD, MPH, medical director of PECP, describes one of this program’s greatest successes as its ability to “build a large network of community partners.” In particular, PECP has partnered with a local family support network. A representative from this network regularly attends team meetings to provide input and feedback on the program.
The project includes bilingual community care coordinators such as Aura Anania, BSW, MSW, who work to link families to community resources—both medical and non-medical. In a recent interview with the National Center for Medical Home Implementation (NCMHI), Ms Anania described one of the successes of care coordination as the “linking of parents to resources in the community they didn’t even know existed.” Ms Anania describes parents as feeling more “at ease” knowing that they have a care coordinator to contact who speaks their language. For more information about this HTPCP grant, visit the American Academy of Pediatrics Community Pediatrics grants database.
(Back to Top)
Medical Home Chapter Champions Program on Asthma (MHCCPA)
Through the support of the Merck Childhood Asthma Network, Inc. (MCAN), the MHCCPA facilitates the dissemination of best practices and advocacy related to the implementation of the National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines within the medical home framework. Program goals include identifying a champion at the AAP chapter and/or state level(s) to educate/mentor providers in their communities, in addition to increasing advocacy efforts, for implementation of the NHLBI guidelines within the context of a medical home. If you would like to be connected with your chapter champion or are interested in more information about the project, fill out the Contact Us form.
Children's Health Insurance Program Reauthorization Act (CHIPRA) Grants—Cycle I
North Carolina is a lead on one of 10 CHIPRA grants, representing single-state projects and multi-state collaborations, from HHS to improve health care quality and delivery systems for children enrolled in Medicaid and the Children's Health Insurance Program (CHIP). The money will help states implement and evaluate provider performance measures and utilize health information technologies such as pediatric electronic health records and other quality improvement initiatives.
LEND Programs Receive Funding to Improve the Health of Children with Special Health Care Needs
The Health Resources and Services Administration (HRSA) has awarded $28.3 million to 43 Leadership Education in Neurodevelopmental and Other Related Disabilities (LEND) programs, including the program at the University of North Carolina at Chapel Hill, to help improve the health of infants, children, adolescents and young adults with neurodevelopmental and other related disabilities, including autism spectrum disorders. LEND programs prepare trainees from a wide variety of professional disciplines to assume leadership roles, ensure high levels of interdisciplinary clinical competence, and enhance the ability of clinicians to diagnose, treat, and manage complex disabilities in youth and adolescents.
Consortium to Advance Medical Homes for Medicaid and CHIP Participants
National Academy for State Health Policy (NASHP)—January 2011
Fifteen state teams, including North Carolina, were brought together by the NASHP to form a Consortium to Advance Medical Homes for Medicaid and Children's Health Insurance Program (CHIP) Participants. These states worked together to develop and implement policies that increase Medicaid and CHIP program participants' access to high performing medical homes. For more information, see the blog post, Constructive Ideas from Medical Home Builders, and the report, Building Medical Homes: Lessons from Eight States with Emerging Programs.
Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration
North Carolina will participate in the MAPCP Demonstration that will include up to approximately 1,200 medical homes across eight states serving up to one million Medicare beneficiaries. All major payers in the states or proposed regions (Medicare, Medicaid, as well as a significant representation of the large private insurers/managed care organizations) will be participating, thereby assuring the availability of sufficient resources to the primary care practice for implementation of the advanced primary care model.
State Initiatives in Patient-Centered Medical Homes
The Council of State Governments
The majority of state Medicaid programs are testing models of coordinated medical care to improve quality and reduce costs, particularly for patients wit h multiple chronic illnesses. This brief includes descriptions of eleven states' pilot programs or authorizing legislation including North Carolina.
Reducing Disparities at the Practice Site
Center for Health Care Strategies, Inc. 2008-2011
Small provider practices play a critical role in caring for Medicaid beneficiaries, particularly those who are racially and ethnically diverse. Funded by Robert Wood Johnson Foundation, this initiative was developed by CHCS to support quality improvement in small practices serving this population. The three-year project is helped Medicaid agencies and health plans partner with small practices to reduce racial and ethnic disparities and improve overall outcomes. State-led teams in Michigan, North Carolina, Oklahoma and Pennsylvania are helped practice sites implement interventions focused on tracking patients and outcomes using an electronic data management tool; adopting evidence-based guidelines for targeted chronic conditions; and incorporating team-based care into ongoing practice operations. Click here to access a brief published in May 2011.
North Carolina IMPaCT: Advancing and Spreading Primary Care Transformation
AHRQ has awarded four Infrastructure for Maintaining Primary Care Transformation (IMPaCT)-Support for Models of Multi-Sector, State-Level Excellence cooperative grants to support model State-level initiatives using primary care extension agents in small and mid-sized independent primary care practices to assist with primary care redesign. By supporting experienced programs and requiring evaluation, AHRQ will seek to demonstrate how a national primary care health extension program could be built.
Fast Facts on Primary Care Practice Support Systems In Select States
National Academy for State Health Policy (NASHP), 2012
This matrix provides an overview of six state projects, including North Carolina, that help providers deliver high-powered primary care and discusses how the teams, pods, and networks support practices, draw on federal health reform resources, and much more.
National Asthma Control Initiative (NACI) Demonstration Projects (2012-2013)
The National Heart, Lung, and Blood Institute’s NACI has announced funding of 13 demonstration projects across the US, including a project in North Carolina, aimed to develop, implement, and test science-based approaches to improve asthma control using evidence-based national guidelines for diagnosis and managing asthma. Additionally, the NACI Web site hosts a variety of tools for health care professionals related to diagnosis and treatment of asthma.
The Assuring Better Child Health and Development (ABCD) Program
The ABCD Program is funded by the Commonwealth Fund, administered by National Academy for State Health Policy (NASHP), and designed to assist states in improving the delivery of early child development services for low-income children and their families by strengthening primary health care services and systems that support the healthy development of young children, ages 0-3. The program focuses particularly on preventive care of children whose health care is covered by state health care programs, especially Medicaid. Since 2000, the ABCD program has helped twenty-seven states create models of service delivery and financing through a laboratory for program development and innovation.
- The Enduring Influence of the ABCD Initiative
In May 1999, NASHP and The Commonwealth Fund launched the ABCD initiative in. North Carolina was one of the early states to be awarded a grant through this project. This report offers lessons, strategies, and policies learned over the past 12 years through this initiative.
- Comments: 12 Years of ABCD
This document contains comments from Dr Marian Earls, Lead Pediatric Consultant, Community Care of North Carolina. Dr Earls has been involved with ABCD in North Carolina since its inception with ABCD I in 2000. In this document, Dr Earls discusses the outcomes that North Carolina has achieved through its ABCD work over the past twelve years.
- Setting the Stage for Success: The NC ABCD Project 2000-Present
This presentation by Dr Marian Earls provides a history of ABCD in North Carolina. The presentation details the start of ABCD in North Carolina with ABCD I in 2000 and how Community Care of North Carolina has sustained the work since Commonwealth funding for ABCD ended. The presentation also details results and successes achieved by the project, and offers lessons learned for other states.
National Center for Children’s Vision and Eye Health
Prevent Blindness America—the nation’s leading volunteer eye health and safety organization—has established the National Center for Children’s Vision and Eye Health, made possible by a multi-year cooperative agreement from the MCHB. The program is designed to serve as a major resource for the establishment of a public health infrastructure to advance and promote children’s vision and eye care, as well as provide leadership development, health promotion, education, and training to public and private entities throughout the US.
Health Resources and Services Administration (HRSA) in Your State
HRSA in Your State offers overviews of HRSA programs and current information, such as the number and amount of grants awarded down to the County level. It also provides state-specific information about health centers, National Health Service Corps members and the communities they serve, and the number of participating providers through the 340B program.
Early Childhood Comprehensive Systems (ECCS) State Contacts
The Maternal and Child Health Bureau (MCHB) launched the State Maternal and Child Health Early Childhood Comprehensive Systems (ECCS) Initiative to implement the MCHB Strategic Plan for Early Childhood Health. The purpose of ECCS is to support states and communities in their efforts to build and integrate early childhood service systems that address the critical components of access to comprehensive health services and medical homes; social-emotional development and mental health of young children; early care and education; parenting education, and family support. For additional information, you can look up your state's ECCS Grantee Contact or Grantee Web site.
AAP: Community Pediatrics Grant Database
The Community Pediatrics Grant Database archives previously funded Community Pediatrics grant projects, including those funded through the CATCH Program, the Healthy Tomorrows Partnership for Children Program, the Community Pediatrics Training Initiative and the Healthy People 2010 Chapter Grants. The database is searchable by seven major categories: target population; health topic; state/territory; project activity; AAP program; AAP district; and project year. Members of the AAP can obtain grantee contact information by searching through the Member Center. If you are not an AAP member, but have questions please contact email@example.com.
Child Health Accountable Care Collaborative
Community Care of North Carolina has implemented the Child Health Accountable Care Collaborative as the result of a 3-year award from the Centers for Medicare and Medicaid Innovations Center that began in July 2012. The collaborative, which provides enhanced care coordination to children with complex chronic illnesses served through the Medicaid and Child Health Insurance Program, is estimated to save just over $24 million.
Care Coordination for Children
In 2011, North Carolina established the Care Coordination for Children (CC4C) program, an at-risk population management program for young children from birth to five years of age. Each child enrolled in CC4C is assigned to a medical home and a CC4C care manager in an effort to improve health outcomes and reduce costs for this high-need population.
This page houses information on funding opportunities from the AAP and other organizations, as well as links to other key funding contacts and resources.
(Back to Top)
This section provides information on state organizations that play a role in implementing various aspects of medical home, and includes links to their Web sites and contact information.
American Academy of Pediatrics (AAP) Chapter—North Carolina
AAP chapters are organized groups of pediatrician members and other health care professionals working to achieve AAP goals in their communities. Please contact your local chapter for additional state resources.
American Academy of Family Physicians (AAFP) Chapter—North Carolina
AAFP represents more than 94,000 family physicians, family medicine residents, and medical students.
Family Voices Chapter—North Carolina
Family Voices aims to achieve family-centered care for all children and youth with special health care needs (CYSHCN) and/or disabilities. Through a national network of chapters, they provide families with tools to advocate for improved public and private policies, and build partnerships among professionals and families.
Family-to-Family Health Information Centers (F2F HICs)
F2F HICs are non-profit organizations that help families of CYSHCN and the professionals who serve them. F2F HICs are typically staffed by parents of CYSHCN who understand the issues that families face, provide advice, offer resources, and tap into a network of other families and professionals for support and information.
Exceptional Children's Assistance Center (ECAC)
907 Barra Row Suite 102-013, Davidson, NC 28036-8104
Phone: 704/892-1321| Toll-Free: 800/962-6817
Primay Contacts: Marlyn Wells 919/571-8092, Yolanda Black 704/892-1321, Grace Sisco 704/892-1321
Brochures: ECAC Brochure and NC F2FHIC Brochure
Title V Maternal and Child Health (MCH) Director & Children with Special Health Care Needs (CSHCN) Director
Title V of the Social Security Act is the nation's oldest federal program to improve the health of all mothers, infants, children, adolescents, and CSHCN. Title V is administered by the Federal Maternal and Child Health Bureau (MCHB) as a block grant to states to support core public health functions, such as care coordination and rehabilitation services.
Early Hearing Detection & Intervention (EHDI) Contact(s)
State EHDI programs promote universal newborn hearing screening, develop effective tracking and follow-up as a part of the public health system, promote appropriate and timely diagnosis of hearing loss, prompt enrollment in appropriate early intervention, ensure a medical home for all newborns, and strive to eliminate geographic and financial barriers to service access.
State Newborn Screening & Genetics Programs
Early Intervention/Part C Coordinators
The Program for Infants and Toddlers with Disabilities (Part C of IDEA) is a federal grant program that assists states in operating a comprehensive statewide program of early intervention services for infants and toddlers with disabilities, ages birth through 2 years, and their families.
State Section 619/Special Education for ages 3-5 Coordinators
This program provides free appropriate public education (FAPE) for children, ages 3 through 5 years, with disabilities.
State Interagency Coordinating Council (ICC) Chairs
This program advises appropriate agencies on the unmet needs in early childhood special education and early intervention programs for children with disabilities, assists in the development and implementation of policies that constitute a statewide system, and assists all appropriate agencies in achieving full participation, coordination, and cooperation for implementation of statewide system.
Children's Health Insurance Program (CHIP)
CHIP is Title XXI of the Social Security Act and is a state and federal partnership that targets uninsured children and pregnant women in families with incomes too high to qualify for most state Medicaid programs, but often too low to afford private coverage. Within federal guidelines, each state determines the design of its individual CHIP program, including eligibility parameters, benefit packages, and administrative procedures. The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 re-authorized the program through FY 2013, and includes many incentives for states to find and enroll more eligible children in both Medicaid and CHIP. CHIPRA also includes quality provisions that aim to monitor and improve care delivered through the Medicaid and CHIP programs. Each state does have a CHIP program, and the names of these programs differ from state to state. To find information on health coverage programs in your state, visit the InsureKidsNow.gov Web site.
Medicaid State Directors
Medicaid is Title XIX of the Social Security Act and is a federal/state entitlement program that provides medical assistance to certain individuals and families with low incomes and/or special health care needs. Medicaid is of unique importance to children; together with the CHIP, Medicaid insures more than one in four children in the United States, with millions more eligible but currently unenrolled. The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is a critical component of Medicaid, which guarantees that children enrolled in Medicaid are screened for medical or developmental problems early, and that necessary treatments and services are provided. To find information on health coverage programs in your state, visit the InsureKidsNow.gov Web site.
- Medicaid State Reports—2011
The American Academy of Pediatrics, in partnership with the National Association of Children's Hospitals, has created fact sheets that explain the importance of the Medicaid program, and how children in every state rely on it for their health care.
Community Health Centers in the State
HRSA provides a searchable database of federally-funded health centers. Health centers provide care to those with or without health insurance including well-care check ups, treatment when sick, complete care during pregnancy, immunizations and checkups for children, dental care, prescription drugs, and mental health and substance abuse care.
Regional Extension Centers (RECs)
Health Information Technology RECs support and serve health care providers to help them quickly become adept and meaningful users of electronic health records (EHRs). RECs are designed to make sure that primary care clinicians get the help they need to use EHRs by providing training in adopting EHRs, guidance with implementation, and technical assistance as needed.
North Carolina Commission on Children with Special Health Care Needs
The eight member Commission is charged with monitoring and evaluating the availability and provision of health services for children with special health care needs in NC and to monitor and evaluate the services for special needs children through NC Health Choice, the health insurance program for children. The Commission makes recommendations for modifications or additions to the rules necessary to improve services to these children and make service delivery more efficient and effective. Contact: Division of Public Health, 919/707-5000.
North Carolina Health Choice for Children
NC Health Choice for Children covers uninsured children whose family incomes do not exceed 200% of the federal poverty level. The Medicaid and NC Health Choice application and renewal processes utilize joint application/renewal forms; out-stationed eligibility workers; mail-in option; multiple application sites; elimination of assets tests; continuous eligibility for twelve months; and elimination of child support enforcement as an eligibility condition.
Community Care of North Carolina
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.
North Carolina Healthy Start Foundation
Since 1993, the Division of Public Health as the state Title V Agency has utilized the NC HSF for their coordination of maternal and child health public education/public awareness campaigns and their materials development expertise.
Health Check facilitates regular preventive medical care and the diagnosis and treatment of any health problem found during a screening. The program has approximately 105 community-based Health Check Coordinators throughout the state whose primary responsibility is to connect families with information and resources.
North Carolina Department of Insurance
Provides information for consumers on their rights in accessing health insurance coverage. Includes information on when and how a pre-existing health care condition impacts a person's ability to access coverage. Also provides listings for licensed insurance companies that provide major medical health plans in NC.
North Carolina Office on Disability and Health (ODH)
A partnership between the Women's and Children's Health Section and the FPG Institute at the University of North Carolina at Chapel Hill, the ODH aims to improve access to health promotion and disease prevention opportunities for people with disabilities through collaboration with state and community public health programs and disability service networks.
Smart Start is a public-private initiative that provides early education funding to all of the state's 100 counties. Smart Start funds are administered at the local level through local nonprofit organizations called Local Partnerships.
State of North Carolina
This Web site provides links to all North Carolina state agencies and services.
(Back to Top)
Association of Maternal and Child Health Programs (AMCHP)—North Carolina State Profile
These state profiles provide a snapshot of how the Maternal and Child Health Block Grant (Title V) works in specific states. The profiles detail the federal funds appropriated to each state, state match, specific programs funded, numbers of people receiving services and state health needs.
Early Childhood State Policy Profiles
National Center for Children in Poverty (NCCP)
NCCP’s Early Childhood Profiles were produced as part of the Improving the Odds for Young Children project. These comprehensive profiles highlight states’ policy choices that promote health, education, and strong families alongside other contextual data related to the well-being of young children.
Issue Brief: Implementing the Medical Home in Medicaid, CHIP, and Multistakeholder Demonstration Programs
American Academy of Pediatrics (Member access only)
This Issue Brief serves to provide guidance to AAP chapters working with states to implement medical home projects in Medicaid and CHIP as well as multipayer demonstration programs. It also addresses a number of the policy questions that frequently arise in creating state supports for the medical home.
(Back to Top)
Medical Home Data Portal—State Data Pages
Child and Adolescent Health Measurement Initiative
The Medical Home State Data Portal profiles provide a state’s medical home performance level for all children and children with special health care needs, based on data from the 2009/2010 National Survey on Children with Special Health Care Needs, 2007 National Survey on Children's Health and the 2005/2006 National Survey of Children with Special Health Care Needs.
Child Health USA 2013
US Department of Health and Human Services, Health Resources and Services Administration
This annual statistical report highlights the health status and service needs of America's children. The report contains easy-to-access graphs and charts summarizing significant indicators of children's health status, statistics, figures, and references.
America's Children: Key National Indicators of Well-Being, 2011
Federal Interagency Forum on Child and Family Statistics
The purposes of the report are to improve Federal data on children and families and make these data available in an easy-to-use, non-technical format. It organizes well-being indicators into seven sections: family and social environment, economic circumstances, health care, physical environment and safety, behavior, education, and health.
KIDS COUNT Databook
Annie E Casey Foundation
This report is a national and state-by-state profile of the well-being of America's children available as an interactive databook, a complete PDF-format report, and on request, in print. Data and rankings on 10 key indicators of child well-being are available by state, county, and city.
State-at-a-Glance Chartbook on Coverage and Financing for Children and Youth with Special Health Care Needs
The Catalyst Center
The Online State-at-a-Glance Chartbook provides data on carefully selected indicators of health coverage and health care financing for CYSHCN. Using the online Chartbook, you can access data for your state and easily compare it with both national averages and other states' data.
National Healthcare Quality & Disparities Reports
Agency for Health Research and Quality (AHRQ)
50-State Demographics Wizard
National Center for Children in Poverty (NCCP)
This tool allows you to create custom tables of national- and state-level statistics about low-income or poor children. Choose areas of interest, such as parental education, parental employment, marital status, and race/ethnicity—among many other variables.
Adolescent Health Database
National Adolescent Health Information Center (NAHIC)
The NAHIC database includes national and state-level profiles of key measures of the health of adolescents and young adults. National-level data is available by gender and race/ethnicity and also state-by-state, with summaries, data tables, and guidance for using this data to improve the health of adolescents and young adults.
Medical Home Data Fact Sheet—January 2009
American Academy of Pediatrics
To inform key aspects of the pediatric medical home, the AAP has compiled a data fact sheet of summary statistics and facts from various AAP and public and proprietary sources. These data define the current state of pediatric care, and as the efforts surrounding the promotion and expansion of the pediatric medical home accelerate, the fact sheet will change to reflect this new picture.
Profile of Pediatric Visits—April 2010
American Academy of Pediatrics
This report is based on the most current available four years worth of NAMCS and MEPS data (2004-2007). The updated report includes annualized estimates by source of payment, patient age, physician specialty, well vs sick visit, office setting, practice ownership, physician employment status, and geographic location.
(Back to Top)
AAP Child Health Informatics Center—State and Territory Specific HIT Resources
This page on the AAP AAP Child Health Informatics Center (CHIC) Web site allows you to identify pediatric specific HIT resources by state related to Meaningful Use, Regional Extension Centers, State Health Information Exchanges, and other important information.
Community Care of North Carolina Online Toolkit
This statewide, locally-operated program provides support for practices to help them function as medical homes. The toolkit provides a step-by-step guide to creating and managing programs similar to Community Care. The site is organized into 16 modules, each of which focuses on a topic such as developing care management support or integrating behavioral health. The Commonwealth Fund provided support for the creation of the online toolkit.
Supporting “Meaningful Use” of HIT in Small, High-Volume Medicaid Practices
Robert Wood Johnson Foundation
This brief describes how Oklahoma, Michigan, North Carolina and Pennsylvania are, through reducing disparities at the practice site, supporting practice improvements among Medicaid-serving providers by helping them to adopt and implement electronic registries.
Articles Related to North Carolina Medical Home Activities
(Back to Top)