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How North Carolina is Implementing Multi-Faceted SDOH Transformation

 |  By Laura Beerman  
   October 12, 2022

"The ultimate goal is to make sure that fragmented systems begin to come together to serve our communities," says one program executive.

Since 2019, North Carolina has launched a statewide referral network, begun implementing and expanding a novel 1115 waiver demonstration, transitioned its Medicaid program to managed care, and added an innovative social care payments platform—all in the middle of COVID-19.

HealthLeaders interviewed LaQuana Palmer, program director at NCCARE360, who was previously the Healthy Opportunities program manager, putting her on the front row of North Carolina's health equity transformation.

Says Palmer: "The ultimate goal is to make sure that fragmented systems begin to come together to serve our communities. I think that was the biggest thing that that came out of this work that we were all doing together."

Three interlinked initiatives

Healthy Opportunities is a statewide framework and infrastructure that can support innovation in the private sector and promote opportunities for health for all North Carolinians. Under this umbrella are the Healthy Opportunity Pilots, a comprehensive program to test and evaluate the impact of providing select evidence-based, non-medical interventions to high-needs Medicaid enrollees as part of the state's newest 1115 demonstration waiver.

NCCARE360 puts into place the statewide infrastructure for all payers and providers—including providers in at-risk contracts—to address the social drivers of health that account for almost 80% of health outcomes. Its building blocks include:

  • A robust statewide resource directory.
  • A resource team that includes dedicated navigators.
  • A shared technology platform that enables providers to assess for and identify unmet social needs, and then send and receive secure electronic referrals and track outcomes.
  • A community engagement team working with community-based organizations (CBOs), social service agencies, health systems, independent providers, and more to create a statewide, coordinated care network.

Within NCCARE360 for the Healthy Opportunities Pilots are Advance Pilot Functionalities with invoicing mechanisms that facilitate Medicaid payment to CBOs.

This payment is for providing social services to Medicaid beneficiaries who meet the eligibility criteria to qualify for the Healthy Opportunities Pilots.

"The strategy that was taken was to look at Healthy Opportunities, to ensure that we were looking at whole-person health, and how NCCARE360 fits into that. It is the infrastructure and the network that helps with linking a fragmented system."

How NCCARE360 grew

As of July 2022, NCCARE360 had served more than 98,000 clients for a full variety of non-clinical needs supported by:

  • 2,863 organizations in-network
  • 7,130 individual programs
  • 47,311 network users

Palmer detailed how NCCARE360 and its broader work started with "the nuts and bolts of resource repositories and getting all of the directories together into a network that links different providers so there is a No Wrong Door approach."

She adds: "We were building the NCCARE360 network in the midst of responding to COVID. During this time, a number of the organizations were using the newly developed NCCARE360 network and wanted to be a part of the Healthy Opportunities Pilot work but were also recovering from the economic effects of the pandemic.

The approach was careful and incremental.

When the Healthy Opportunities Network Leads were identified, the organizations worked with the North Carolina Department of Health and Human Services to build their capacity—staff, organizational, and program development.

"There was a lot of work that went on ahead of time to make sure that we were prepared when we went live," says Palmer. "We rolled organizations on with a couple of weeks in between to ensure we had the staff to answer questions.

"At the end of 2020 was when we really began to look at rolling on each of our payers, onboarding them to ensure they are using what we've built and that there was an understanding of the workflows of the organizations that use NCCARE360."

These payers are the state's seven Local Management Entities/Managed Care Organizations are responsible for public mental health, intellectual and developmental disabilities, and substance use disorder services for people who are uninsured or are covered by Medicaid.

The role of technology and public-private partnership

To function as designed, NCCARE360 required technology and financial connectors between consumers, traditional providers, CBOs, and other organizations.

The Foundation for Health Leadership and Innovation (FHLI) played a vital role. It is the administrator of NCCARE360, which is the public-private partnership between FHLI and DHHS. The partnership also includes United Way of North Carolina and NC 211.

It also includes two technology partners. Expound Decision Systems has created a data repository model to manage state social determinants of health resources. Unite Us, an enterprise technology company connecting health and social care, supports both NCCARE360 and the Healthy Opportunities Pilot, the latter as of Q1 2022 through Social Care Payments.

Unite Us describes Social Care Payments as the first integrated social care payments platform "designed to bridge the gap between healthcare funders and [CBOs]" and "the only end-to-end solution for social care that streamlines the implementation and management of paid social care programs."

Says Palmer: "We were looking for an organization that could come in and not only look at how we are linking to services but could combine both technology and engagement. We were able to do that by linking with our partners at Unite Us and United Way of North Carolina and Expound decision making as well."

She adds: "The key takeaway from NCCARE360 and the work we're doing that advances the Health Opportunity work … is the public-private partnership [FHLI]. Many states have never seen this before—the fact that folks from the public sector, nonprofits, and private sector will be able to say, 'We've got an ultimate goal all in mind. We know we all have different systems and needs, but this is an opportunity for us to all come together to make sure that our communities are being served.'"

The path ahead

HealthLeaders also interviewed NCCARE360 VP Darrell Deaton about current obstacles and next steps.

"One of the challenges is to make sure that we have platform interoperability—that's why we are working with Unite Us and an Electronic Health Record (EHR) vendor to integrate information so that when a patient gets a referral from the NCCARE360 platform, the clinicians know they don't have to go different places."

Deaton adds: "We're hoping to pilot the interoperability of the Unite Us platform with a leading EHR platform at a health system in North Carolina. That is a primary function that health systems across the country are asking for to improve their staff workflows and have a patient's social and medical records consolidated in the medical record."

“The strategy that was taken was to look at Healthy Opportunities, to ensure that we were looking at whole-person health, and how NCCARE360 fits into that. It is the infrastructure and the network that helps with linking a fragmented system.”

Laura Beerman is a contributing writer for HealthLeaders.


In years marked by state Medicaid RFP, waiver activity, and increased attention on the social determinants of health, North Carolina stands out.

Public-private partnerships have helped the state launch multiple initiatives to improve health equity.

The picture is one of a careful, incremental development process linking consumers and providers, technology, and payments.

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