Special Programs & Initiatives

Network Specific Programs & Quality Improvement Initiatives

Community Care of the Sandhills is involved in a number of Quality Improvement programs which greatly enhance their ability to provide quality, cost effective care. Below is a description of each program:

Prior to the launch of the ABCD program, North Carolina found low rates of referrals for children by medical practices for early intervention services. Only 2.6 percent of state children between the ages of zero and three were receiving early intervention services, even though a statewide task force estimated that as many as 8 to 13 percent would benefit quality for such services. Identifying children with developmental delays is important in the medical setting, as the child's primary care physician is the best-informed professional with whom families have regular contact during the child's first five years of life. The "ABCD" model was designed for the purpose of developing "best practices" for identifying and referring children, ages 0-5, for early intervention. CCS has partnered with several local Smart Starts within the region to bring this quality project to local providers.

CCS through its Pediatric QI Coordinator continues to provide training and technical assistance to physicians and/or mid-level providers and their office staff to help integrate developmental screening and referrals into designated well-child visits and to help them provide education and information to families regarding their child’s development. CCS's Pediatric QI Coordinator continues to work closely with the CDSA and the school systems to enhance communication and referrals amongst the primary care practices. The Pediatric QI Coordinator is working to expand the project into two new practices per county over the next year, and continues to do chart reviews to provide the state level Smart Start office with data to help demonstrate the effectiveness of the project.
Heart failure has a tremendous impact on individuals’ functional status and quality of life. Heart failure patients are frequently hospitalized and suffer from chronic shortness of breath and fatigue. Medicaid recipients with heart failure face further barriers to optimal health, including low health literacy, transportation issues, and poor access to care. In North Carolina, heart failure is the second leading cause of preventable hospitalizations. Per capita expenditures for individuals with heart failure far exceed those for individuals with asthma or diabetes. The annual mean Medicaid expenditure for individuals with heart failure is $27,000, while it is $7,900 and $12,000 for people with asthma and diabetes, respectively. Fortunately there are opportunities to improve outcomes for people with heart failure. A growing body of evidence suggests that intensive outpatient monitoring and patient self-management support can improve health outcomes and quality of life, and reduce hospitalization rates for patients with heart failure.

CCS, with one care manager dedicated solely to the project, implemented a CHF Telephonic program in 2006. CCS was a leader in the state to help write and implement the telephonic scripts which guide this program. In 2008 CCS became one of three networks to partner with the Department of Health and Human Services to pilot a Heart Failure Telehealth program using telemonitoring technology to provide greater intensive care management, health coaching and clinical support to high risk heart failure patients.

The CCNC heart failure Telehealth pilot sites will aim to:

  • Identify a subset of the population who will benefit from telemonitoring and care management;

  • Assist in patients’ transition from being acutely ill to clinically stable;

  • Increase self management education in targeted population;

  • Improve health outcomes in high risk CCNC recipients with heart failure;

  • Increase adherence rates for medication compliance; and

  • Determine criteria for maximizing technology effectiveness

  • CCS currently has 15 Telehealth monitors active in the community and is awaiting funds to purchase 10 more.

North Carolina is facing the difficult challenge of providing cost-efficient, high-quality acute and long-term care to the most vulnerable Medicaid population – the aged, blind and disabled. This population represents less than 30% of the population but consumes almost 70% of the Medicaid budget. Recognizing that arduous task, the North Carolina General Assembly directed the NC Department of Health and Human Services “to expand the scope of Community Care of North Carolina’s care management model to recipients of Medicaid and dually eligible individuals with a chronic condition and long-term care needs”.

The CCNC networks have partnered with the Department of Health and Human Services to pilot a chronic care initiative targeting those individuals who are aged, blind and disabled who would benefit most from linkages with a care manager and primary care physician (“PCP”).

Through this Chronic Care project CCS aims to:

  • Reorganize the delivery of care to those with chronic needs in ways that enhance appropriate access;

  • Increase service delivery options;

  • Improve efficiencies in the identification, assessment and care planning process;

  • Identify a subset of the population who will benefit from care and disease management;

  • Strengthen the linkage with the PCP medical home;

  • Create individualized care plans and link individuals, when appropriate, with existing disease and pharmacy management initiatives;

  • Reduce variations in care;

  • Reduce the rate of institutionalizations; and

  • Reduce the unnecessary inefficiencies and expenses inherent in the current system.

To further enhance the Chronic Care project, CCS is presently implementing a Transitional Care program that focuses on care management services closer to the point of care. CCS has established a remote connection to all seven hospitals allowing care managers to review daily hospital records on all hospitalized Medicaid patients in real-time. These patients are then visited by the care manager before discharge and then again at home within 72 hours of discharge. The primary purpose of the follow-up home visit is medication reconciliation. A transitional care summary report is produced in collaboration with the care manager and the network pharmacist. The objective is to make this report available at the time of the patient’s post hospitalization visit to their medical home.

Several networks in the CCNC program began seeing an increasing number of Medicaid enrollees at primary care provider practices with both behavioral and physical health care needs. As a result of efforts in mental health reform and changes in the local service delivery infrastructure, CCNC networks working in concert with their local management entities (“LMEs”) are piloting a collaborative approach to managing Medicaid enrollees who have both behavioral and physical health needs and serve them in the most appropriate setting. The primary goal of the mental health integration pilot is to work on program model development that focuses on: Integrating the identification and care of depression in the primary care provider’s office; Implementing the four Quadrant Model as the platform for screening, identification, and triage of complex needs patients (combined medical and behavioral concerns); and Demonstrating effectiveness in communication and consultation between primary care physicians and mental health providers.

The pilot aimed to do the following: Increase the comfort level of primary care providers in identifying and treating people with depression who present in their office; Improve communication between the PCPs and behavioral health care providers; Adopt standardized screening, assessment, reporting and communication tools; Implement co-location models, when feasible; Ensure, through improved coordination, that patients are able to access care at a point in the system where their health and behavioral health needs are optimally met; and Adopt uniform process and outcome measurements for program evaluation. Through this pilot CCS assisted in the implementation of a very successful co-location site with one of its largest pediatric offices. This practice was able to integrate a licensed clinical social worker into the practice and further expand the project to include telepsychiatry.

The push toward E-Prescribing began in earnest following a 2006 report from the Institute of Medicine that found at least 1.5 million Americans experience adverse drug events (“ADEs”) each year. Outpatient Medicare beneficiaries were estimated to experience 530,000 adverse drug events annually. One of the recommended solutions was to make greater use of health information technologies in prescribing and dispensing medications. E-Prescribing is a significant opportunity for technology to make an impact on patient safety and physician efficiency. It is an important component of the “meaningful use” requirement.

CCS is committed to stimulating the adoption of E-Prescribing or stimulating higher rates of E-Prescribing in practices that are activated to E-Prescribe, but experience workflow and education barriers. CCS offers help with evaluation, vendor selection and training. With the assistance of grant monies, CCS plans to continue the effort to promote E-Prescribing within the network. Practices are offered scholarships and consultant time to help with adoption and integration of E-Prescribing.

The HealthCheck Program was developed in 1993 as a statewide initiative to ensure children, ages birth through 21years, fully utilize their medical home for preventative health and sick care services.  The Program is administered as a cooperative venture between DMA/CCNC and the DPH - Women's and Children's Health Section.  HealthCheck participants are eligible to receive comprehensive well child checkups, immunizations, and vision, hearing, and dental screening services on a regular basis throughout childhood.

HealthCheck Coordinators assist families in obtaining medical benefits and other community services and support needed by their children. They reach out to communities to educate families, consumers, and health care providers about HealthCheck and HealthChoice and to help enroll eligible children.  HealthCheck Coordinators network with other child-focused agencies and organizations within their communities to ensure coordination of care and that appropriate referrals can be made.

There are currently two HealthCheck Coordinators located within CCS's seven county network.  Direct supervision is provided by CCS's Pediatric QI Coordinator.  The HealthCheck Coordinators reach out to families and communities, educating the caregivers on the importance of annual well child checks, timely immunizations, dental services, and recommended follow-up care, as well as assisting parents in overcoming barriers that would hinder them from receiving these benefits.  For more information contact:

Kimberly DeBerry, RN BSN CCM
OB/Pediatrics Program Manager
Community Care of the Sandhills
Office: 910-246-9806
Cell: 910-585-9775

Stroke is a leading cause of death and disability among Americans, and a major contributor to health-related racial disparities. The Centers for Disease Control and Prevention predicts a continued increase in the number of deaths due to stroke, and a sharp rise in the number of survivors with physical dependency or need for institutionalization, unless prevention and control initiatives are escalated. Bountiful evidence exists that the risk of stroke is not being optimally reduced for Americans at risk. Ninety percent (90%) of middle-aged Americans will develop high blood pressure in their lifetime, and 70% who have it now do not have it under control. CCS has partnered with the Department of Health and Human Services to pilot an adult stroke prevention initiative targeting approximately 3,500 individuals with hypertension.

CCS will aim to:

  • Promote evidence based practice guidelines for blood pressure management, coronary vascular risk assessment, and risk factor management by distributing provider toolkits and conducting trainings for participating primary care practices;
  • Test patient and practice incentive strategies that impact practice performance, patient self management and health outcomes; and
  • Determine practice systems and process that support effective control of hypertension and implementation of stroke prevention strategies.

Through this grant funded project CCS has been able to hire a care manager dedicated to administering the Bosworth Tool to our HTN patients with low adherence indicators for hypertensive needs. The Bosworth Tool is a telephonic scripted tool that was developed by Dr. Hayden Bosworth with the VA hospitals. These grant funds have also made it possible for CCS to purchase electronic blood pressure cuffs for enrollees who agree to participate in the program.

Improving performing in practice is aimed at transforming the way we deliver health care by providing doctors the tools, systems and support needed to provide consistently high quality care to all patients at all times. CCS, through its Quality Improvement Consultant (“QIC”), works on-site with the practice leadership to develop a practice-specific redesign plan utilizing the resources of collaborating experts.

CCS has partnered with Southern Regional AHEC to implement the IPIP program. Currently, CCS has three practices participating in the IPIP project and several others in beginning stages of improvement project implementation. CCS has also partnered with FirstHealth to implement a Health and Wellness Trust Fund grant which focuses on health disparities with diabetes. Through this grant, SCCN will be assisting to implement “group medical visits” in primary care practices within the CCS region. CCS has also partnered with AHEC to work on this project in conjunction with FirstHealth. The practices will not only receive support to start the group medical visits, but they will also be able to receive continuing medical education (“CME”) credits as well.

CCS is currently looking to expand IPIP into other areas of the network. CCS is part of an HTN/Stroke Prevention grant project. In realizing that CCS needs to offer provider education on the treatment of HTN, it is felt that utilizing IPIP to affect true practice change in workflow is the most effective way to impact the way practices treat their HTN patient population. IPIP is implementing a new “change package” for HTN. CCS and AHEC’s QIC will begin implementation of IPIP with some of our practices that have high HTN numbers in the coming months.

The Pregnancy Medical Home (PMH) program was implemented in 2011 and is designed to provide comprehensive, coordinated maternity care to pregnant Medicaid patients.  The program aims to improve the quality of maternity care, improve outcomes for mothers and babies, and reduce medical care costs.  The model involves engaging obstetrical providers as Pregnancy Medical Homes and local health departments as providers of Pregnancy Care Management services.  CCS has an OB Physician Champion and a OBCM Lead Coordinator responsible for recruiting and supporting practices.

The Pregnancy Medical Home program is an outcome-driven initiative monitored for specific performance standards.  By participating, maternity care providers receive financial incentives for risk screenings and evaluations, as well as ongoing support from an OBCM Care Coordinator.  In turn, practices agree to work toward quality improvement goals, including reducing elective deliveries prior to 39 weeks, performing standardized initial risk screening, using 17P to prevent recurrent preterm birth, reducing primary C-section rates and collaborating with pregnancy care management programs to serve high-risk patients.  For more information contact:

Kimberly DeBerry, RN BSN CCM
OB/Pediatrics Program Manager
Community Care of the Sandhills
Office:  910-246-9806
Cell: 910-585-9775

Helpful tools for physicians and patients are available at

Link to the PMH Care Pathway on the Management of Substance Use in Pregnancy


The Care Coordination for Children (CC4C) program is administered as a partnership between Community Care of North Carolina (CCNC), the NC Division of Public Health (DPH) and the NC Division of Medical Assistance (DMA). Local health departments provide Care Management services for children 0-5 with referrals originating from primary care medical homes, hospitals, community organizations, families and CCS Care Management staff.  The main goals of the program are to improve health outcomes and reduce costs for enrolled children.  Care Management services are provided to children who meet one or more of the following priority risk factors: special health care needs; chronic physical, developmental, behavioral or emotional condition; exposed to toxic stress in early childhood; foster care; NICU babies; high emergency department utilization and costs.  

CC4C is an outcome-driven initiative monitored for specific performance standards.  The success of the program will be measured by: length of time from NICU discharge to first medical home visit; hospital admissions, readmissions and ED use; and the number of children with special health care needs and/or children in foster care who have a medical home.  CCS's Pediatric QI Coordinator manages the program and utilizes reports based on data from CMIS, Medicaid claims, vital records and other administrative sources for quality improvement purposes and to identify the extent to which the program is achieving its goals.  For more information contact:

Kimberly DeBerry RN BSN CCM
OB/Pediatrics Program Manager
Community Care of the Sandhills
Office: 910-246-9806
Cell: 910-585-9775