laura zink marx president & ceo united way of north ...united way of north carolina. taylor...

Laura Zink MarxPresident & CEOUnited Way of North Carolina

Taylor JusticeCo-Founder and CEOUnite Us

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PROPRIETARY & CONFIDENTIAL

What is NCCARE360?

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NCCARE360 is the first statewide coordinated network that includes a robust data repository of shared resources and connects healthcare and human services providers together to collectively provide the opportunity for health to North Carolinians.

NCCARE360 Partners:


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Building a Healthier North CarolinaPart of a Broader Statewide Framework

3PROPRIETARY & CONFIDENTIAL

The Solution:

1. Uniform system for providers, insurers, and community organizations to coordinate care, collaborate, and track progress and outcomes.

2. Tool to make it easier to connect people with the community resources they need to be healthy.

3. Track statewide, regional, and community –level data on service delivery and outcomes achieved.

The Problem: Connecting people to community resources is inconsistent, not coordinated, not secure, and not trackable.

Multi-Faceted ApproachPromoting the Opportunity

for Health

Standardized Screening

Map SDOH Indicators

Medicaid Managed

Care1. Statewide Core

Components2. Regional Pilots

Align enrollment w/

existing resources

Work Force(Community

Health Workers)

NCCARE360


Helping ALL North Carolinians

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PROPRIETARY & CONFIDENTIAL 5

Three Functions


Functionality Partner Timeline

Resource Directory

Call Center Support

Directory of statewide resources verified by a professional data team

adhering to AIRS standards

24/7/365 call center with a team of NCCARE360 Navigators, and the

addition of text and chat capabilities.

Ongoing work

Resource Repository APIs integrate resource

directories across the state to share resource data.

Phased Approach

Referral & Outcomes Platform

Community Engagement Managers

Referral platform with closed loop functions.

Community Engagement Managers for workflow, change management,

continued in person t

Rolled out by county January 2019 –

December 2020


Five Key Pillars of NCCARE360

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HousingFood Stability Interpersonal

ViolenceTransportation Employment


Resource Directory

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Updated 8/31/19 Org

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Unduplicated Total 2664 6727 695 384 830 440 210 860 644 2664


Data Repository

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• Multiple Directories• Multiple Vendors• Proprietary Formats• Non-Standardized content• Unique ways to transmit data• Hard to keep updated

• No Universally accepted schema• No authoritative “aggregator”• Industry incentivized to disaggregate• No easy way for users to consume

data• Current way: technically complex &

costly

The Data Solution

?Source A

Source B

Source C

Trusted Repository


Your Community Resources in One Place

In Coordinated NetworkOrganizations onboarded to the platform – Coordinated Network

• Agree to NCCARE360 platform requirements

• Have completed training and on-boarding

• Responsibility to report outcomes

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Out of NetworkOrganizations that have not been onboarded to the platform

• Searchable and Identifiable as part of Resource Directory/Data Repository

• Not part of the NCCARE360 platform yet

• Do not report outcomes


A coordinated network connects providers (such as health care providers, insurers, or community organizations) through a shared technology platform to:

• Communicate in real-time• Make electronic referrals• Securely share client information• Track outcomes together

NCCARE360Creating a Collaborative Network through Shared Technology Platform



✖ Service provider cannot always exchange PII or PHI via a secure method

✖ Limited prescreening for eligibility, capacity, or geography

✖ Onus is usually on the client to reach the organization to which he/she was referred

✖ Service providers have limited insight or feedback loop

✖ Client data is siloed & transactional data is not tracked

All information is stored and transferred on HIPAA compliant platform

Client is matched with the provider for which he/she qualifies

Client’s information is captured once and shared on his/her behalf

Service providers have insight into the entire client journey

Longitudinal data is tracked to allow for informed decision making by community care teams

Traditional Referral Through NCCARE360

Client Healthcare Provider Food Provider Client Healthcare Provider Food Provider

Coordination Platform at workImproving coordination efficiency and accuracy


PROPRIETARY & CONFIDENTIALPROPRIETARY & CONFIDENTIAL

Network Model: No Wrong Door ApproachUnderstanding Referral Workflows

Client Care Coordinator

FoodProvider

Employment Provider

Housing Need Identified along with

other needsAdditional Needs

Identified

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Referral Referral


Configurable Screening:Patient and/or provider facing algorithmic screenings to stratify risk and identify specific co-occurring needs

Electronic Referral Management:Seamless referral workflow sends the right data to the right provider(s) to address specific needs

Assessment/Care Plan Management:Custom care plans for each service need that are attached to referrals so receiving providers get a head start

Bi-Directional Communication/Alerts:Automated notifications keep all organizations up to date, while care team members can securely communicate with each other

Outcomes:You get to know exactly what services were delivered, and the entire history for every intervention by your external partners

From Hello to Outcome, You are ConnectedAutomated workflows between your external partners at scale

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Privacy & Security

HOUSING PROVIDER

CLIENT

EMPLOYMENT

DOCTOR

MENTAL HEALTH

Protected information (e.g. outcomes for Mental Health or Substance Use cases) is restricted from view based on users’ viewing permissions.

Compliant with Health Insurance Portability and Accountability Act (HIPAA) & Personally Identifiable Information (PII) standards

Compliant with Security & Data Storage Standards and Breach & Enforcement Rules

Informed consent is requested by the system ONCE, before the first referral is made. Clients consent to have their information shared in order to receive

services from network partners.

INFORMED CONSENT FOR PARTICIPATION & INFORMATION SHARING


Patient Demographics, Patient Access Points, Service Delivery History, Outcome Breakdowns

Service Episode history (longitudinal), Referrals Created, Received by, Structured Patient Outcomes for each specific need addressed

Patient Level Coordination and Tracking Network Level Transparency & Accountability

The Data You NeedReal-time reporting of outcomes, impact, performance & efficiency

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Employment Service Type Example

Configurable & Structured ReportingGranular and detailed outcomes for every type of service

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NCCARE360 Data Elements

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Network Performance

Network Impact

Network Efficiency Community/Client Impact

• Total number of in-network providers/organizations

• Referral Traffic (e.g. # of referrals)

• % of outcomes accepted

• # of clients served • Number of out-of-

network referrals

• Accuracy of referrals

• Needs addressed

• % of cases closed with positive outcome

• Median time to be connected to in-network organization

• Median time to in-network case closure

• Number of open/closed cases

• Clients served• Client impact

(e.g. # of services with resolved outcome)

• Client outcome (e.g. resource person with food insecurity received)

• Community resource gaps analysis


Data from a Coordinated Network in Charlotte, NC (Powered by Unite Us)

Improved Efficiency in North CarolinaAccelerating intake, referral, and closing the loop


IN CHARLOTTE, NC


Status Update

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NCCARE360 Status Update

15 Counties launched

30 Counties started on implementation

1520 Organizations engaged in socialization process

316 Organizations with NCCARE360 licenses

1389 Active Users

318 Lives Impacted

26%

11%

8%18%

7%

7%

23%

Engaged Organizations by Service

Healthcare

Housing

Employment

Food

Interpersonal Safety

Transportation

Other


Network Launch Plan

Strategy Sessions

Outreach to Partners

Partner Registration Training Launch

•Discuss network objectives & project design

•Software demo

•Answer partner questions

•Identify additional partners

• Partners provide information on:- staff who will

be using the software

- eligibility for programs/ services for which staff will receive referrals

•Unite Us trains partners in-person on the software

•Network goes live!

•Ongoing software training webinars and live support provided by Unite Us

•Ongoing network growth

•Learn about partners’ current referral workflows

•Determine programs/ departments and staff to participate at launch


EHR SMART on FHIR Integration


Questions

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laura zink marx president & ceo united way of north ...united way of north carolina. taylor...

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