North Carolina’s Care Network

According to North Carolina’s Department of Health and Human Services (DHHS), Division of Public Health’s Annual Report Submitted to the North Carolina Medical Society (NCMS) (October 2019), “Access to high quality medical care is crucial to health, but research shows that up to 80 percent of a person’s health is driven by social, economic, and environmental factors that determine behaviors that emerge as a result.”

These drivers are often referred to as “Social Determinants of Health (SDOH) and includes housing, food, education, employment, transportation, and safety. However, not all healthcare and social needs providers and community based organizations provide limited types of assistance or are well connected to other organizations able to meet all the total needs of a person. DHHS has been working to create a multi-faceted network to unite communities and the healthcare system to effectively deliver health, not just healthcare.

To assist with SDOH, North Carolina’s network called NCCARE360, was established as a statewide coordinated network to unite healthcare and human services organizations. The network is the result of a public-private partnership with the Foundation of Health Leadership and Innovation

The participating organizations in the network include clinicians, social workers, care coordinators, families and other community-based organizations to provide a coordinated community-oriented and person-centered approach to deliver care in the state.

“NCCARE360” allows providers to electronically connect to community resources and allows for a feedback loop on the outcome of that connection. This solution ensures accountability for services delivered, closes the loop on every referral made, and reports on the outcomes of that connection.

“NCCARE360” will enable community partners access to:

  • A robust statewide resource directory to include a call center with dedicated navigators, a data team verifying resources along with text and chat capabilities
  • A data repository to integrate resource directories across the state to share resource data
  • A shared  technology platform to enable healthcare and human service providers to send and receive secure electronic referrals, seamlessly communicate in real-time, securely share client information, and track outcomes
  • A community engagement team available to work with community-based organizations, social service agencies, health systems, independent providers, and others to create a state-wide coordinated care network.


The network is going to improve the health of all North Carolinians which includes the commercially insured Medicare, Medicaid, uninsured, military, and veteran populations. The network is live in many counties in the state and statewide implementation is expected by the end of 2020.

In addition, according to the Report presented to the NCMS, a multi-disciplinary Technical Advisory Group was formed to develop screening to use to identify needs related to food, housing, transportation, and interpersonal violence.

Field testing the screening questions in safety net clinical settings along with telephonic care management, has showed high levels of acceptability, understandability, and comfort with the screening questions. The highest unmet need identified was food security with 40% of respondents reporting that have experienced a period of food insecurity in the past 12 months.

In addition, according to the DHHS report, the Medicaid Managed Care section, “Healthy Opportunities Pilots” presents an unprecedented opportunity to create a system to deliver health-related social needs services, pay for health-related social needs services, and evaluate evidence-based non-medical interventions available to higher risk Medicaid Managed Care enrollees.

Go to for the “Annual Report to the North Carolina Medical Society 9October 2019).

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