Medical Homes in North Carolina
This page is designed to keep you informed about events and activities happening in North Carolina that will help improve access to medical homes for children with special health care needs (CSHCN).

»Medical Home Initiatives	»Resources
»Related Grant Initiatives	»Educational Initiatives
»Partners in the State	»Screening Initiatives

Medical Home Initiatives
This section provides information on state medical home initiatives/programs. States that are a part of the mentorship network will have a "Promise to the State" which outlines how they will achieve ensuring that all children have a medical home by 2010. This is based on the Healthy People 2010 goals which is a 10 year action plan to achieve and measure success for all CSHCN.

North Carolina Medical Home Contact:

Name: Danielle Matula - Specialized Services Unit
Contact: Phone: 919-707-5674 | Email: Danielle.Matula@ncmail.net

North Carolina was selected to be part of the first National NICHQ Medical Home Learning Collaborative - A fifteen-month collaborative activity to improve care for the growing population of CSHCN. This initiative focused on 3 practices in the state and assisted them in completing a quality improvement process to provide medical homes to their patients with special needs. NC worked with NICHQ staff to provide training regarding Medical Homes for CSHCN. For more information you can go to the project overview.

North Carolina Statewide Medical Home Implementation Plan - Promise to the State

• Update on Medical Home Activities: August, 2004

Related Grant Initiatives
This section provides information on current state grants that are working on medical home initiatives. This includes the grant abstract as well as key contacts for the grant.

Community Systems Building Champions Incentive Grant - Incentive Award FAQs
Goal: To create a Family Advisory Council which will work with the North Carolina CYSHCN Unit to design data training modules and implement data training with state and community shareholders. The data training will provide an important resource for families and communities to utilize as they work to design local initiatives that will improve outcomes for families of CYSHCN.
For more information contact: Marlyn Wells, Family Liaison Specialist, C&YB
Phone: 919-707-5675 | Email: Marlyn.Wells@ncmail.net

Early Childhood Comprehensive Systems Planning Grant: Abstract
Purpose: The overall goal of this planning project is to develop a comprehensive early childhood service system that will allow multiple agencies to work towards and document progress in achieving school readiness for all children entering elementary school in NC. The plan will serve to coordinate services of a number of state agencies, and will incorporate activities and priorities of other organizations to create a plan that will guide and assist multiple stakeholders.

Name: Deborah Nelson, PhD., ECCS Grant Coordinator
Contact: 919-707-5677 | Fax: 919-870-4880
E-Mail: deborah.nelson@ncmail.net

Hemophilia Grant: Abstract
Purpose: The 8 federally funded hemophilia treatment centers from Region IV North in the states of Kentucky, North Carolina, South Carolina, and Tennessee provide comprehensive care, including a full complement of medical and psychosocial services, for all children and adults with bleeding disorders. This regional network of comprehensive prevention services is provided at the treatment centers by teams of physicians, nurses, social workers, orthopedists, dentists, physical therapists, laboratory technicians, and other appropriate personnel to over 1,700 individuals with bleeding disorders.

Healthy Tomorrows Partnership for Children Grants 2005-2010

Connecting the Dots
University of North Carolina Chapel Hill, Chapel Hill, NC
Purpose: The goal of this project will be to establish a hierarchy of services to prevent problem behaviors among children in out-of-home childcare from becoming behavioral and psychosocial health conditions. Child Care Health Consultants will offer consultation and technical assistance to out-of-home childcare providers to improve their response to challenging behaviors. Children needing medical services will be screened and referred to their medical homes for primary health services, and those with more serious needs will be referred on to pediatric mental health services. Click here for more information on this project.

For more information on the Healthy Tomorrows Grant Program click here. For more information on this HTPCP project, please e-mail your name, address, telephone, and fax numbers with your specific request to healthyt@aap.org.

Partners in the State
This section provides information on who in the state (individuals and agencies) are working together to create medical homes for children.

American Academy of Pediatrics (AAP) Chapter: NC Pediatric Society (NCPS) www.ncpeds.org
The mission of the North Carolina Chapter of the American Academy of Pediatrics and the North Carolina Pediatric Society is to improve the health and well being of children through the collective efforts of its membership and to provide an organization for professional communication, education, and fellowship. The NCPS Web site provides information about membership and upcoming events, a calendar, and related links.

American Academy of Family Physicians (AAFP) Chapter: www.ncafp.com/
The North Carolina Academy of Family Physicians, founded in 1948, is a professional association representing more than 2500 family physicians, family medicine residents and medical students across NC. Affiliated with the American Academy of Family Physicians, NCAFP's goal is to advance the specialty of family medicine and advocate for the interests of family physicians.

The North Carolina Title V and CSHCN Program are located within the DHHS Division of Public Health’s Women’s and Children’s Health Section.

Name: Dr. Kevin Ryan
Contact: 919-707-5512 | Fax: 919-870-4880
E-Mail: Kevin.Rayn@ncmail.net

Name: Carol Tant, Title V CSHCN Director
Contact: 919-707-5610 | Fax: 919-870-4880
E-Mail: Carol.Tant @ncmail.net

State Web Site: wch.dhhs.state.nc.us/cay.htm

Title V Block Grant to States
Title V of the Social Security Act is one of the largest Federal block grant programs. It leads the nation in ensuring the health of all mothers, infants, children, adolescents, and children with special health care needs (CSHCN). Title V is administered by the Maternal and Child Health Bureau (MCHB) as part of the Health Resources and Services Administration, U.S. Department of Health and Human Services.

Title V and Children with Special Health Care Needs
MCHB Objective: Support development and implementation of comprehensive, culturally competent, coordinated systems of care for the estimated 18 million U.S. children who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally

NC Commission on Children with Special Health Care Needs
The Commission on Children with Special Health Care Needs is appointed by the Governor of NC and is legislatively charged to monitor and evaluate the availability and provision of health services to children with special health care needs in NC. In addition they are responsible for monitoring and evaluating services provided to children with special health care needs under the child health insurance program, NC Health Choice for Children. The Commission meets every other month in Raleigh, NC.

Name: Danielle Matula
Contact: Phone: 919-707-5674 | Email: Danielle.Matula@ncmail.net

NC CSHCN Program and Specialized Services Unit
Programs and services focus on the special health care needs of infants, children and adolescents with (or at risk for) chronic illnesses or developmental disabilities. Families of children with special health care needs are involved in policy development, planning and program implementation. Service priorities include case management/care coordination, disability issues, access to care, transition for children (for example, from early childhood to school age and school age to adult); and linking children with medical homes. The Child Service Coordination Program (CSCP), Children’s Special Health Services (CSHS) Purchase of Medical Care Program, CSHS health care and specialty clinics, Assistive Technology Programs for young children and the NC Office on Disability and Health are located in this unit.

Name: Carol Tant, Children and Youth Branch Head
Contact: 919-707-5610 | Fax: 919-870-4880
E-Mail: carol.tant@ncmail.net

Medicaid: www.dhhs.state.nc.us/dma/covgroups.htm
Medicaid is the largest publicly funded source of insurance for North Carolina children from birth to 21 years of age. The program is administered by the DMA at the state level, and locally by county Departments of Social Services. North Carolina’s Medicaid program provides coverage for a comprehensive array of primary and preventive services. The majority of children are eligible under the Medicaid for Infants and Children (MIC) coverage category which insures infants at or below 185% of federal poverty level; children ages 1 through 5 at or below 133% FPL; and children ages 6 through 18 at or below poverty. Other children/adolescents are eligible through the following programs: Medicaid for Families with Dependent Children; Medicaid for Pregnant Women; Work First Family Assistance (TANF); SSI-Disabled Children; Special Assistance to the Blind; or Children in Foster Care. Additional children are served through the CAP Medicaid Waiver Programs.

Carolina Access
Carolina Access was introduced in 1991 as Medicaid’s primary care case management program, linking Medicaid recipients with a primary care provider (PCP). The PCP acts as a gatekeeper to provide and arrange for most of families’ health care needs. Carolina Access is active in all 100 NC counties and has become a national model for its strong support both among providers and recipients. Currently, there are approximately 670,000 Medicaid recipients in the program and 86,894 are children under six years of age. With the exception of the one county with a Medicaid managed Health Maintenance Organization, Carolina Access II/III serves as the primary vehicle for managing this population in this state.

Carolina Access II & III or NC's Community Care Plans
Carolina Access II/III was launched in 1998 under the leadership of a past Secretary of NC’s Department of Health and Human Services. Access II/III builds on Carolina Access by working with public and private providers to form community-based systems of care to better manage services to the Medicaid population by devoting attention to issues of quality and cost. Providers take responsibility for the enrolled Medicaid population, to provide preventive services and to develop processes by which at-risk patients can be identified and their care managed. The following features distinguish the plans:

• Bringing together local community representatives, consumers, and providers to plan and develop comprehensive and integrated systems of care
• Identifying at-risk enrollees through claims and assessment
• Implementing targeted case management;
• Developing and measuring budget, utilization, and quality targets;
• Developing ongoing commitment to community needs and values; and
• Strengthening the community “safety-net” for serving the indigent population.

Each Access II/III network is expected to form a collaborative governance structure. The network either forms a new not-for-profit organization or uses an existing public or private non-profit organization. In both cases, decision-making and responsibility are to rest with the community partners. Each “not-for profit administrative entity” receives a $2.50 per member per month (pm/pm) enhanced care management fee that is budgeted and used to provide the resources to manage the Medicaid population , such as hiring local care managers. Physician committees carry out most of the clinical oversight work of the organization. Each project sets up a Medical Management Committee to set the organization’s direction relative to the project’s care and disease management priorities.

Currently, there are approximately 470,000 Medicaid recipients in the program and 146,485 are children under six years of age. The NC legislature has mandated that Carolina Access II/III expand statewide to include over 600,000 of the people eligible for Carolina Access by June 2004. The NC Secretary of the Department of Health and Human Services (DHHS) has identified this as a top priority.

NC Healthy Start Foundation: www.nchealthystart.org
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. The NC HSF utilizes cost-effective, and culturally/linguistically appropriate outreach strategies and has produced Health Check/Health Choice campaign educational and promotional materials in two languages; and has engaged both television and radio. The Health Check/Health Choice Steering Committee’s realized that while outreach efforts were successful in reaching eligible families for enrollment and re-enrollment, many of these families were not accustomed to having access to regular health care and were not using, to the best advantage, their health check/Health Choice benefits. From that realization, a campaign to encourage the development of the Medical Home began. Over the past year, the NC HSF Health Check/Health Choice Campaign Coordinator has been interviewing families, providers and outreach workers in order to determine effective strategies, themes and messages for this new Medical Home Campaign.

Health Check: www.dhhs.state.nc.us/dma/healthcheck.htm
Health Check, started in 1993, was DMA’s enhanced replacement for the Early Periodic Screening Diagnosis and Treatment Program (EPSDT) for children birth through 20 years of age. 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. They have access to an Automated Information and Notification System (AINS) to track enrollees’ use of the health care system through claims. Currently, both the Health Check and Health Choice programs allow 26 unmanaged outpatient mental health visits annually and a non-specific diagnosis is allowed for the first six visits. (CSHCN can receive additional outpatient visits with prior approval.)

Name: Jeffrey Simms, Assistant Director, DMA (Managed Care and Health Check)
Contact: 919-647-8188
E-Mail: Jeffrey.Simms@ncmail.net

Name: Carolyn Sexton, Health Check/Health Choice Coordinator, DPH
Contact: 919-707-5642
E-Mail: carolyn.sexton@ncmail.net

NC Health Choice for Children
Over 104,000 children age 18 and under are currently enrolled in NC’s state child health insurance program (SCHIP). NC Health Choice for Children covers uninsured children whose family incomes do not exceed 200% of the federal poverty level. It is a non-entitlement program -- the number served is dependent upon availability of funds. The benefits package is the same as that provided through the state employees’ health plan (NC Teachers' and State Employees Comprehensive Major Medical Plan), with the addition of both preventive and maintenance dental coverage along with vision and hearing coverage. Benefits for children with special needs are modeled on Medicaid guidelines, except that services for long-term care are not covered, and respite care may be provided under emergency circumstances. A provision for reimbursement for case management for CSHCN as a cost containment and quality assurance measure is an approved benefit. This provision has not been fully implemented. Families with incomes 150% of the federal poverty level must pay an annual enrollment fee of $50 per child or $100 maximum for two or more children. Children must be uninsured on the date that NC Health Choice enrollment begins. Co-payments are required for these families as follows:prescriptions - $1, $3 and $10 depending upon whether the drug is generic or name brand; $5 for each physician, clinic, dental or optometry visit except that there are no co-payments for preventive services;$5 for outpatient hospital visits; and $20 co-payment for non-emergent care provided in the emergency room.

Enrollees whose income has risen to 200%-225% FPL by re-enrollment may buy-in for one year at full cost. 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. On-going outreach campaigns help assure maximum enrollment.

Name: Cinnamon Narron, NC Health Choice Coordinator, DMA
Contact: 919-855-4020
E-Mail: Cinnamon.Narron@ncmail.net
Web site: www.dhhs.state.nc.us/dma/cpcont.htm

North Carolina Office on Disability and Health (ODH): www.fpg.unc.edu/~ncodh
Since 1994, the NC Office on Disability and Health (NCODH) has been organized as a partnership agreement between the Women’s and Children’s Health Section and the FPG Institute at the University of North Carolina at Chapel Hill.

The goals of the NCODH are to increase awareness and understanding of the health-related needs of individuals with disabilities; improve access and inclusion; develop health promotion programs and educational materials for consumers and professionals; conduct and report on research and data collection; and affect disability policy related to these areas. The ODH is sponsoring initiatives in four primary areas: 1) access to health care; 2) women’s health; 3) adolescents and young adults in transition; and 4) physical fitness and recreation.

The NCODH supports the Division of Public Health and the NC DHHS with disability and health leadership in building state capacity to effectively address and eliminate health disparities. The goal of the Office, consistent with that of the Division, is 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.

Name: Karen Luken, NC ODH Program Director
Contact: 919-966-0868 Fax: 919-966-0862
E-Mail: kluken@email.unc.edu

Smart Start - Smart Start is a public-private initiative that provides early education funding to all of the state's100 counties. Smart Start funds are administered at the local level through local nonprofit organizations called Local Partnerships. The North Carolina Partnership for Children (NCPC) is the statewide nonprofit organization that provides oversight and technical assistance for local partnerships. Services at the local level vary depending on local needs. www.smartstart-nc.org/

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 the hearing loss, prompt enrollment in appropriate Early Intervention, link newborns to a medical home and strive to eliminate geographic and financial barriers to service access.

The newborn hearing and metabolic screening programs have been joined to create the Genetics and Newborn Screening Unit. This unit focuses on consultation, education, diagnostic testing, counseling and family support related to various genetic conditions as well as identification, referral, diagnosis, amplification, and intervention specific to hearing loss. Major service initiatives include newborn screening and follow-up for both hearing and metabolic disorders, genetic counseling, consultation to families and to private and public providers. Regional genetic counselors, regional child health audiology and speech language consultants, and program consultants focus on these initiatives.

Name: Joan Crissey, MA CCC-SLP Unit Manager Genetics and Newborn Screening
Contact: Phone: 919-707-5630 | Fax: 919-733-2997
E-mail: joan.crissey@ncmail.net
Web site: www.ncnewbornhearing.org

Early Intervention/Part C Coordinator:
The NC Infant-Toddler Program is North Carolina’s interagency early intervention program for children ages birth to three. The Division of Public Health (WCHS, Early Intervention Branch) is the lead agency. Children with diagnosed developmental delays, chronic illnesses, disabilities or other risk factors for developmental delay are eligible for program services. The goal of program interventions is to assure optimal physical, social, and emotional development for children with special needs. Multidisciplinary program service providers and family members jointly develop an Individualized Family Service Plan (IFSP) based on professional assessments of child’s needs and other issues of concern to the family. The IFSP is used to guide subsequent care decisions. The program provides or arranges for assistance in obtaining all services that are required to address issues contained in the ISFP. Program services are provided based on the child’s needs and family interests. The 19 required early intervention services are:

Name: Deborah Carroll, EI Branch Head
Contact: Phone: (919) 715-7500 x251 | Fax: (919) 733-3075
Email: deborah.carroll@ncmail.net
Web site: www.ncei.org

Section 619/ Preschool Grants Program of the Individuals with Disabilities Education Act (IDEA). This program provides free appropriate public education (FAPE) for children, ages 3 through 5 years, with disabilities:

Name: Kathryn Baars, 619 Coordinator
Contact: Phone: (919) 807-3994 | Fax: (919) 807-3998
Email: kbaars@dpi.state.nc.us
Web site: www.ncpublicschools.org/ec/specialprograms/resources/

State Interagency Coordinating Council (ICC) Chairs:
The North Carolina ICC 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.

Name: Cheryl Mulloy, ICC Co-Chair
Contact: Phone:(704) 894-9885

Name: Azell Reeves, ICC Co-Chair
Contact: Phone: (336) 334-7665 | Fax: (336) 334-7580
Email: reevesi@ncat.edu

Web site: www.ncei.org/ei/ncicc.html

Resources/Documents
Official web site of the state of North Carolina and Governor Mike Easley: www.ncgov.com
This Web site provides links to all NC state agencies and services.

State Waiver Information: www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/08_WavMap.asp
Waivers are the result of a process that allows state Medicaid agencies to apply for and receive permission from HCFA to provide services not otherwise covered by Medicaid and/or to do so in ways not described by the Social Security Act. Most Medicaid managed care programs require Waivers. The Waivers, which can differ greatly, are known by their numbers (1115, 1119), or as home-and community-based, or as Katie Beckett Waivers, CAP-C, CAP-D or CAP-MR/DD.

Additional Medical Home Web Sites and Resources - fact sheet

Educational Initiatives
This section provides information on training initiatives on the medical home. Some states will discuss their outreach projects in relation to physicians, families, and the community.

No information is currently available for this category.

Screening Initiatives
This section provides information on surveillance and screening initiatives in the state.

State Newborn Screening & Genetics Programs: genes-r-us.uthscsa.edu/resources.htm

• State Newborn Screening Program Links
• State Genetics Program Links
• Regional Genetics and Newborn Screening Collaborative Links
• Newborn Screening State Contact Fact Sheet

Assuring Better Health and Child Development (ABCD) Program:
http://12.109.133.213/_docdisp_page.cfm?LID=2A7898BB-5310-11D6-BCF000A0CC558925
The Assuring Better Child Health and Development (ABCD) Program is funded by the Commonwealth Fund, administered by National Academy of State Health Policy, and designed to assist states in improving the delivery of early child development services for low-income children and their families.

NC was one of four states awarded a grant from the Commonwealth Fund in 2001 for development and implementation of programs to enhance child development services by improving service delivery and financing systems. NC’s approach to this initiative has utilized the Access II/III networks as its foundation. Partnership for Health Management (P4HM), championed by Dr. Marian Earls, Developmental Pediatrician, led the development of the model. In subsequent years, the model has been expanded to two additional Access II/III networks and is slated for statewide expansion across Access II/III in 2004. The program goals are to develop a comprehensive community model to be used as a template for replication, and to form a state advisory group to work in concert with tier-one activities. These goals are being reached by:

• Development and implementation of a model program for children that encompasses their health, social, and developmental needs;
• Securing local community involvement and buy-in on the delivery of early childhood developmental services;
• Integration of services in order to assure maximally effective use of current resources and to minimize duplication of service;
• Assisting parents to understand developmental milestones/behavior and ways to facilitate healthy development;
• Identify and respond to provider concerns regarding developmental screening
  and surveillance in private practice;
• Identifying and responding to family concerns; and
• Monitoring and tracking the impact of the project’s effort by implementing an
  evaluative process.

The NC ABCD initiative has centered on interventions in private practices to integrate developmental screening and surveillance into the practice workflow, and to increase early and appropriate referral for children with developmental delays (or risk factors for such delays).

Name: Sherry Hay, Office of Research, Demonstrations and Rural Health Development
Contact: 919-715-1511
E-mail: sherry.hay@ncmail.net

State Resources on the Internet

Note: The information provided on the state pages was submitted by the state medical home teams.As this is not an exhaustive list, please let us know if you have additions for your state resource page. You can contact us at: medical home@aap.org.

Last Updated August 14, 2006