The Division of Community Health offers care management services to multiple populations of all ages, insured and uninsured, serving roughly 100,000 residents of Durham, Granville, Vance, Warren, Person and Franklin counties in North Carolina.

Why is care management important?

At the core of the patient-centered medical home clinical approach is team-based  care that provides care management and supports individuals in their self-management goals. In a report prepared for The Commonwealth Fund, care management was identified as being among the few policy options that hold promise not only of containing costs but also of improving health outcomes for high-risk populations.

Care Management/Subgroups

The Division of Community Health provides “intensive” care management to particular patient populations. Patients from each group are referred to the different care management programs by a medical home provider or identified by predictive modeling programs. The Division of Community Health, along with its health care partners, selected the care management groups based upon timely patient data, clinical decision support capability, and impact and effectiveness of Division of Community Health care management programs.

Social and Medical Complexity

The Division of Community Health provides intensive care management to an average of 30 individuals/day with complex psycho-social conditions compounded with multiple chronic disease and experiencing multiple acute episodes through the following programs:

Medical and Behavioral Complexity

NPCC and Alliance Behavioral Health (ABH) operate a joint care management team of RNs and LCSWs (IHTC) to provide care management services for Quad II and Quad IV Medicaid patients to prevent unnecessary utilization of acute facilities and improve patients quality of life. 

Hospital Transitions of Care

Division of Community Health's NPCC, Just For Us and Duke Connected Care programs utilize Coleman’s coaching model and Just for Us patients receive home base transitional clinical care from advances practice providers and MDs.   

Chronic Disease

NPCC and LATCH care managers, health educators, and community health workers provide a variety of chronic disease management services including two Tele-coaching programs: one for patients with Hypertension and Diabetes and another tele-coaching program for patients with Sickle Cell who are prescribed Hydroxuria.