Thank you to all our partners working in health and social care during COVID-19. Visit cdc.gov/coronavirus for up-to-date information.

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.

Read More

Who Implemented


How To Get Started

Schedule one-on-one time with our VP of Regulatory Affairs to explore funding opportunities in your state.


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 Community Engagement Manager

Megan Lee Carlson

Senior Community Engagement Manager

From a nonprofit partner:

"NCCARE360’s coordinated and comprehensive referral system saves time and money for community action agencies and families served. It’s a long awaited game changer for human service delivery organizations.”
- Sharon C. Goodson, Executive Director of the NC Community Action Association
From a healthcare partner:

"NCCARE360 has been a wonderful platform for our Care Managers to use to assist our patients with much needed resources. One care manager was able to get much needed assistance for a patient within 24 hours. Our team is enjoying the wider array of services we are able to connect our patients with and we look forward to it only getting better as more organizations join."
– Ruth Craig, BSN, RN, CCM. Manager, Medicaid Care Management. Access East, Inc.
From a United Way partner:

"Thanks to the vision and work of NCCARE360 the United Way of Wayne County has built stronger partnerships with our non-profits creating critical and intentional collaborations.”
– Sherry Archibald, Executive Director of United Way of Wayne County
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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.