Rain

Social Work Program 

The following services are provided by the North Carolina Alliance:

Program Services

  • Care Coordination for Children - CC4C
  • Pregnancy Care Managers - PCM

CC4C

Care Coordination for Children (CC4C) is a population management model in partnership with Community Care Networks and Local Care Management Entities that, in addition to the community based interventions for children to maximize health outcomes, will target the highest risk and highest cost children for care management.

CC4C Care Managers

CC4C services will be provided based on patient-need and according to risk stratification guidelines. Contacts will be determined by the patient’s individual needs and plan of care, in order to effectively meet desired outcomes. Contacts may occur in multiple settings including the health care provider office, community, or patient’s home, as well as by phone. CC4C services will continue until the identified need(s) is met, or until progress in meeting the need is no longer being made.

Who is Eligible?

Care Management services are provided for all Medicaid children birth to 5 years of age who are determined to be high-risk and qualify for services. All patients identified as having priority risk factors will be assessed by a CC4C care managers.

For more information about CC4C or to make a referral - Call 250-5219

PCM

Pregnancy Care Managers

All patients identified as having priority risk factors will be assessed by a pregnancy care manager. Priority risk factors include: A history of preterm birth, a history of low birth weight, multiple gestation, fetal complications, chronic conditions which may complicate pregnancy, unsafe living environment (homelessness, inadequate housing, violence or abuse), substance use, tobacco use, missing two or more prenatal appointments without rescheduling, and inappropriate hospital utilization. All Pregnancy Medical Home (PMH) providers are required to complete a pregnancy risk screening to identify these and other risk factors.  Non-PMH providers will be able to refer their patients/clients for Pregnancy Care Management services using the referral form below.

Who is Eligible?

These services are provided for pregnant Medicaid recipients who are determined to be at risk for poor birth outcome.

For more information about CC4C or to make a referral - Call 250-5219