Perinatal Nurse Champion (PNC) Grant
North Carolina is one of nine states to receive the Maternal Health Innovation (MHI) Grant from the Health Resources and Services Administration (HRSA). Funded in September 2019, this five-year federal grant is managed by the Women, Infant, and Community Wellness Section in the Division of Public Health and funds over a dozen contractors around the state to develop innovative strategies to address disparities in maternal morbidity and mortality.
Healthy Opportunities Pilot
The Healthy Opportunities Pilot (HOP) program is the nation’s first comprehensive program to test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation and interpersonal safety and toxic stress to Medicaid Managed Care enrollees.
For more information, click the links below:
- » About HOP
- » CCLCF HSO
- » HSO Network
- » Data
Medicaid Care Management
Community Care of the Lower Cape Fear was selected by NC Medicaid program to manage enrollee’s medical, social, and behavioral conditions by a team focused on client-centered care.
Pathway To Wellness
An established care team focused services designed to support targeted community and family members by linking community resources and aiding in navigating the healthcare system to maximum quality of life.
For specific services under Pathway to Wellness, click the links below:
- "Senior Services: Population Health Support
We keep our focus local
Community Care of the Lower Cape Fear (CCLCF) is changing the healthcare experience. We bring over 18 years of experience providing locally-based care management with a proven strategy for health care quality improvement and cost reduction to southeastern North Carolina. We work with Prepaid Health Plans, ACOs, practices and providers to improve patient outcomes, experience, and satisfaction. CCLCF is an independent, 501(c)(3) nonprofit and a National Committee for Quality Assurance (NCQA) accredited organization.
Our efforts are focused right here in our community
We’re based out of Wilmington, North Carolina and serve six counties, including Bladen, Columbus, Brunswick, New Hanover, Pender, and Onslow counties. Our care managers live in, and understand, the communities we serve. We meet patients where they are and address barriers to healthier outcomes, including connecting them to resources for food, transportation, housing, and support for interpersonal violence or toxic stress. Our population health team has years of experience working alongside our practices and providers, whether it is engaging them in Practice Transformation or helping to navigate NC Medicaid Transformation. CCLCF staff participates in local community meetings, coalitions, panel discussions, and outreach events so we can continue understanding what our communities need and what resources we can provide to help.
We Do Big Things
CCLCF is an integral part of statewide and local cost savings. CCLCF has been a part of a statewide health care initiative to improve patient engagement, quality of care, and enhanced organizational efficiencies, as well as tangible cost savings. Between 2007 and 2010, leading actuarial firm Milliman, Inc. declared that CCNC and its subcontractors had saved North Carolina over $1 billion.
We are proud of our contribution to Physician Quality Partners (PQP) shared savings, generating $5.3 million in savings while improving care quality. Since 2016, our PQP team provided complex care management to engage and provide whole health care to participating patients. Our care management team strived to meet patients where they were and help to remove barriers to healthier outcomes such as food instability, housing concerns, or access to transportation.
Other accomplishments include:
- Receiving one of three Network Lead awards for the Healthy Opportunities Pilot.
- Receiving a 100, the highest possible score, from the National Committee for Quality Assurance (NCQA) for Three-Year Case Management
- Awarded the 2017 Trillium Health Resources Transforming Lives Award for Care Integration
- Performing better than expected in our Key Performance Indicators (KPI’s), since 2014, including patient admission, per member per month (PMPM) cost, Potentially Preventable 30-Day Readmissions, and emergency department utilization.
- Partnering with DSS in New Hanover, Brunswick and Columbus counties on the Fostering Health NC project (a collaboration among CCNC, NC Pediatric Society, and NC DSS, to ensure each child taken into custody is seen by healthcare providers on an enhanced schedule to assess for trauma, treatment of chronic conditions, and behavioral health needs.
- Partnering with Project Lazarus and the Governor’s Institute to develop a comprehensive statewide strategy to combat unintentional overdoses. CCLCF worked with local pharmacies and NH Harm Reduction Coalition to flood the community with Naloxone. As the need for more access to Medication Assisted Treatment increased, we collaborated with UNC-CH MAT ECHO project to promote and support primary care providers to offer MAT in a best practice design. We currently have 4 primary care providers offering MAT treatment programs.
- Participating in a Mental Health collaboration and solutions task force to develop a strategy to address difficult access to mental health services. As one of the organizations selected by State Senator Michael Lee, this community effort resulted in a legislative grant to support the Trillium NC Hospital Diversion Pilot.
- Collaborating with the New Hanover County Resiliency Task Force to help create “trauma-informed” and “resiliency-informed and focused” communities that share a common understanding of the impact of trauma and chronic stress on the nervous system and how resiliency can be restored or increased. CCLCF has fostered two trainers in the Community Resiliency Model (CRM). This model has been proven to create better coping and healthier populations.
