North Carolina – Medical Homes

Community Care of North Carolina (CCNC)

Most North Carolina Medicaid recipients receive medical home services under the Community Care of North Carolina (CCNC) program. In 1998, CCNC launched as an eight-county, 100,000-enrollee pilot extension of the existing Carolina Access primary care case management (PCCM) program – which served the Aid to Families with Dependent Children (AFDC) population. Today, CCNC’s 14 regional non-profit networks of providers, practices, local health departments and community resources serve over 1 million Medicaid recipients across the state, including Aged, Blind and Disabled (ABD) recipients. For a full history of the CCNC program and its predecessors (which date to 1983), please click here.

Under the CCNC program, both primary care providers and the networks receive a per member per month (PMPM) fee to provide patient care, population management strategies (such as disease and care management, population stratification, preventive services and coordination across delivery settings), as well as support in implementing practice improvements. Evaluation of the CCNC program data has shown both cost savings and quality improvement, and has resulted in the state expanding the program to dual-eligible clients (individuals who qualify for both Medicaid and Medicare).

Other states routinely look to CCNC for guidance when developing and implementing similar programs. Through a Commonwealth Fund grant to the North Carolina Foundation for Advanced Health Programs, CCNC collated lessons learned and sample documents into a tool-kit of best practices for interested parties.

In August 2011, CCNC announced a private-public partnership known as “First in Health,” which will allow employees of GlaxoSmithKline, Kerr Drug, and SAS Institute, Inc. (as well as individuals covered under Blue Cross Blue Shield of North Carolina and the State Health Plan) to utilize the CCNC networks.

In 2010, North Carolina passed Session Law 2010-31, appropriations legislation that, among other things, mandated by July 1, 2012 the Department of Health and Human Services, the Division of Medical Assistance and the North Carolina Community Care Networks (NCCCN) create a comprehensive plan under Community Care of North Carolina (CCNC) that incorporates performance metrics with accountable budget and shared savings payment models. To learn more about accountable care activity in North Carolina, including this pilot, visit the North Carolina page of NASHP’s State Accountable Care Activity Map.

Federal Support:

Last Updated: April 2014

Forming Partnerships
Community Care of North Carolina (CCNC): Community Care of North Carolina is a partnership that includes providers supported by the Medicaid agency (Division of Medical Assistance), Office of Rural Health and Community Care, local health departments, and Departments of Social Services and Hospitals. Each network is run locally by an Executive Director, who oversees a team of case managers, as well as a Medical Director, who works with local physicians who provide input.
In 2006, the North Carolina Governor convened a public-private collaboration of government, payers, and provider representatives to develop and implement a common set of best medical quality standards and measures for asthma, diabetes, congestive heart failure, hypertension and post myocardial infarction care. The Governor’s Quality Initiative, now known as the independent non-profit North Carolina Healthcare Quality Alliance (NCHQA), launched in 2008. The NCHQA Board of Directors also includes consumer and business representation. The NCHQA has played a key role in aligning quality initiatives to support and transform primary care.
Early North Carolina Medicaid medical home projects were made possible by support from the North Carolina Foundation for Advanced Health Programs, Inc. and the Kate B. Reynolds Health Care Trust.
Defining & Recognizing a Medical Home
Definition:
Community Care of North Carolina (CCNC)CCNC describes a medical home as a place to receive preventative and sick care; where patients have continuous relationships with their providers and staff know patients’ medical histories; where patients have enhanced access; and have access to care coordination services. Please see the CCNC member handbook for more information.
Recognition:
Community Care of North Carolina (CCNC)While Community Care of North Carolina (CCNC) actively supports providers seeking NCQA PCMH Recognition, this recognition is not required for CCNC participation. However, the Division of Medical Assistance does require CCNC/Carolina Access providers to:
  • Perform primary care that include certain preventative services;
  • The ability to create and maintain a patient/doctor relationship for the purpose of providing continuity of care;
  • Establish hours of operation for treating patients at least 30 hours per week;
  • Provide access to medical advice/services 24/7;
  • Maintain hospital admitting privileges or have a formal agreement with another doctor based on ages of the members accepted;
  • Refer or authorize services to other providers when the service cannot be provided by the PCP; and
  • Use reports provided by the DMA managed care section as guides in maintaining the level of care that meets the goals of CCNC and patient needs.
Additionally, providers must complete a provider agreement that stipulates additional requirements for the practice. A similar provider agreement exists for pregnancy medical homes.
ACA Section 2703 Health Homes: North Carolina’s health homes program is delivered through the Community Care of North Carolina program; health home providers must meet CCNC’s basic participation requirements, described above.
Medicare Advanced Primary Care Practice (MAPCP)Demonstration: Practices participating in the MAPCP Demonstration program must achieve NCQA Recognition. Furthermore, participating practices in the seven demonstration counties were required to achieve Blue Cross Blue Shield North Carolina (BCBSNC) Blue Quality Physician Program recognition by September 2013.
Aligning Reimbursement & Purchasing
Community Care of North Carolina (CCNC)Currently, Community Care of North Carolina (CCNC) providers and networks both receive per-member per-month (PMPM) payments for each patient under their care in addition to fee-for-service reimbursement.
CCNC providers receive:
  • Aged, Blind and Disabled (ABD) population: $5.00 PMPM
  • Non-ABD population: $2.50 PMPM
CCNC Networks receive:
  • ABD population: $13.72 PMPM
  • Non-ABD population: $3.72 PMPM
Networks return $3.17 and $0.54 monthly for each ABD and non-ABD enrollee to support the central office.
Prior to statewide expansion and ABD participation, CCNC networks and providers both received $2.50 PMPM for each enrollee.
Carolina Access providers not participating in the Community Care of North Carolina program receive $1.00 PMPM.
ACA Section 2703 Health Homes: North Carolina’s health homes program pays practices and networks using the same methodology as the Community Care of North Carolina program, described above.
Medicare Advanced Primary Care Practice (MAPCP)Demonstration: Payments to participating practices vary by payer:
  • Medicare: $2.50-$3.50 in addition to fee-for-service. Payments vary based on level of NCQA PCMH recognition: practices with Level 1 recognition receive $2.50; Level 2 practices receive $3.00; and Level 3 practices receive $3.50.
  • North Carolina Medicaid: Medicaid payments are consistent with the CCNC payment methodology, described above.
  • Blue Cross Blue Shield of North Carolina (BCBSNC) and State Health Plan (administered by BCBSNC): Practices receive enhanced fee-for-service payments for Evaluation & Management codes. Enhanced payments begin when a practice submits its application for NCQA PCMH recognition.
  • Participating CCNC networks in counties also receive per-member per-month payments from each participating payer. See CCNC’s MAPCP Frequently Asked Questions page for more information on how payments are made.
Supporting Practices
Community Care of North Carolina (CCNC)ACA Section 2703 Health Homes, and Medicare Advanced Primary Care Practice (MAPCP) Demonstration: Local community networks provide support to physicians participating in all three programs. Networks consist of:
  • Part to full time paid Medical Director – oversight of quality efforts, meets with practices, holds medical management meetings and serves on State Clinical Directors Committee.
  • Clinical Coordinator – oversees the overall network operations.
  • Local care managers (CM). Small practices share/large practices may have their own assigned CM to support practice’s high risk and high cost population and population management activities.
  • Pharmacists to assist with medication management, poly-pharmacy and poly-prescribing.
  • Networks provide population management support to the practices, including customized reports. They work with practices in the implementation of all Community Care of North Carolina (CCNC) initiatives including:
  • Practice re-design (network staff and/or Improving Performance in Practice [IPIP]/Area Health Education Center staff).
  • Develop relationships with community agencies/organizations including links to mental health, public health, hospitals, etc.
  • Transitional support processes – participate in discharge planning, medication reconciliation.
  • Customize practice and patient tools and educational materials.
  • Sponsor learning sessions for network and practice staff.
  • Facilitate group medical visits for chronic conditions.
  • Targeted outreach to patients that will benefit from care management interventions in concert with medical home.
In addition to providing education programs and informational services, Area Health Education Centers (AHECs) are also helping practices achieve electronic health record (EHR) meaningful use as Regional Extension Centers.
The CCNC Patient-centered Medical Home (PCMH) team hosted eight webinars to help practices achieve 2008 NCQA PCMH Recognitionand has completed a 2008 NCQA PCMH Recognition Workbook. A 2011 NCQA PCMH Recognition webinar series and workbook is in development.
North Carolina also received an Infrastructure for Maintaining Primary Care Transformation (IMPaCT) award from the Agency for Healthcare Research and Quality (AHRQ) in September 2011. North Carolina’s IMPaCT project featured a Regional Leadership Collaborative and a Care Transitions Learning Collaborative to accelerate local-level process improvements and quality improvement in clinical performance measures. The Regional Leadership Collaborative focused on developing leadership and quality improvement skills among regional teams. The Care Transitions Learning Collaborative concentrated on integrating care transitions into primary care practices’ roles as part of the PCMH.
Measuring Results
Community Care of North Carolina (CCNC)Treo Solutions, Inc. has reported that Community Care of North Carolina has saved over $1.5 billion between 2007 and 2009. Mercer, Inc. prepared studies that found annual savings ranging from $154-194 million between 2006 and 2009.
CCNC has also reported that enrollee’s diabetes, asthma, and heart disease HEDIS measures rank in the top 10% nationally (compared to commercial managed care plans).
Practice assessments are completed by local Community Care Program Office using:
  • Medicaid claims data;
  • Pharmacy claims data – web-based pharmacy home program;
  • Case identification reports – risk stratification;
  • Gaps in care analysis reports;
  • Customized queries; and
  • Baseline measures, ongoing monitoring, and trend analysis.
Furthermore, an informatics center can provide feedback reports at the individual, practice, network and state levels. However, certain data (including substance abuse and HIV data) cannot be included in individual reports.
The Brookings Institution will be evaluating the public-private “First in Health” program’s impact on both quality and cost of care.
ACA Section 2703 Health Homes: North Carolina will use claims data, a provider survey, and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient survey to evaluate progress toward the state’s three goals for this state plan amendment:
  1. Reduce avoidable emergency department utilization;
  2. Reduce avoidable hospitalizations; and
  3. Increase integration of primary care and behavioral healthcare.