A Playbook to
Coordinate
Care Across an
Entire State
Meet Lisa
Lisa is a single mom who was experiencing food insecurity, had transportation issues that made it difficult to go to her WIC clinic, and needed breastfeeding support.
Her postpartum home visiting nurse sent an electronic referral via Unite Us to an organization who was able to provide Lisa with food benefits.
The same nurse sent a referral to a Breastfeeding Peer Educator who was able to deliver a pump to Lisa’s home.
Lisa and people just like her are receiving the services they need through coordinated care networks across the country – every single day.
January 2015
NCServes launched in partnership with Institute for Veterans and Military Families, serving veterans, transitioning service-members, and their families.
January 2019
A partnership was born with North Carolina Department of Health and Human Services, Foundation for Health Leadership and Innovation, United Way of North Carolina, Expound Decisions, and Unite Us.
March 2019
The network officially launched with three counties.
January 2020
The network reached 2,000 electronic referrals.
May 2020
1,000 network partners were trained and active.
June 2020
The network was active in all 100 counties.
The Playbook
What You Need
What North Carolina Did
The North Carolina Department of Health and Human Services and the Foundation for Health Leadership and Innovation formed a public-private partnership to ensure sustainable funding.
Who Implemented
What North Carolina Did
United Way of North Carolina’s leadership team works collectively to build upon the existing 211 infrastructure, including a robust resource database, while also engaging the network of local United Ways as champions of NCCARE360.
A dedicated Resource Team verifies local resources and helps inform the engagement strategy. NCCARE360 Navigators, based in the NC 211 call centers, respond to requests for assistance received via www.nccare360.org and support health care providers who need additional help making referrals.
A community repository powered by Expound integrates multiple resource directories across the state and allows data sharing.
Who Implemented
How To Get Started
Identify potential partners in your state – we can help.
What North Carolina Did
Unite Us’ shared technology platform enables health and human services providers to send and receive electronic referrals, seamlessly communicate in real-time, securely share client information, and track outcomes.
Who Implemented
How To Get Started
What North Carolina Did
Unite Us’ community engagement team lives and works in the communities they serve. They work to build awareness, onboard partners, provide ongoing support after launch, and and monitor network health.
Who Implemented
Unite Us Community Engagement Team
How To Get Started
A Day in the Life of a Unite Us Community Engagement Manager
Megan Lee Carlson
Senior Community Engagement Manager
Entry Points to Care
01
Western Carolina Medical Society
recognized a food insecurity need in one of their patients. Not knowing all the available food pantries in the area, the referral was sent to MANNA Food Bank to determine the best fit for the patient..
02
Cone Health
referred a client for environmental modifications/ accessibility to NC-211 (coordination center) who referred the client to NC Vocational Rehab which resulted in the client (an above-the-knee amputee living in a two-story home) receiving help with making his home safer and easier to maneuver.
03
Orange County Health Dept.
referred a client, who was pregnant and on bed rest for rental assistance so she could stay in her home, to Central Piedmont Community Action who accepted.
COVID-19 Strategic Response
Our original goal was to be statewide by the end of 2020. However, when COVID-19 struck, organizations started requesting to be onboarded sooner. “We knew we had to act now, so we created a thoughtful expedited strategy that included virtual community engagement, network health monitoring, and onboarding optimization. NCCARE360 was able to continue because of our team’s ability to pivot and persevere to ensure that all North Carolinians have the resources they need to survive this pandemic,” shared Network Director, Georgina Dukes. The need for statewide public health infrastructure is critical for COVID-19 recovery – as suggested by a 937.5% spike in emergency food referrals this year.
