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Care Coordination

Care Coordination for Children (CC4C)

Care Coordination for Children (CC4C) is an at-risk population management program that serves children from birth to 5 years of age who meet certain risk criteria. The main goals of the program are to improve health outcomes and reduce costs for enrolled children. Each child served by CC4C is linked to a specific Medical Home and CC4C Care Manager. The Care Manager works closely with the local medical practice serving as the child's Medical Home to coordinate roles and responsibilities and ensure the child obtains necessary care. 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.

To refer a patient to CC4C, use the following referrals forms:

Who is Eligible?

CC4C services are provided for all children birth to 5 years of age who meet one of the following risk factors: have special health care needs, are exposed to toxic stress in early childhood, are in the foster care system who need to be linked to a Medical Home, are in the Neonatal Intensive Care Unit who need assistance as they transition back to the community and link to a Medical Home. All patients identified as having priority risk factors will be assessed by a care managers.

Pregnancy Care Management or “OB” Care Managers

Pregnancy Care Management (PCM) is a statewide program in NC promoting healthy mothers and healthy babies. This program provides care management services for high risk women during pregnancy and for two months after delivery by a social worker or nurse. Referrals are made to our program to provide additional support during pregnancy.

OBCM Services Include:

  • Help to identify your needs and make a plan to address them
  • Work closely with you and your doctor to understand your needs
  • Help arrange transportation to medical appointments if needed
  • Help getting into services (WIC, ​Medicaid, family planning)
  • Provide education and information

Currently, all Pregnancy Medical Homes screen New OB patients for this service, non-PMH providers will be able to refer their patients/clients for Pregnancy Care Management services using this referral form.

Who is Eligible?

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

Locate & Contact


Susan Hanlon
Care Coordination Supervisor
P:(828) 250-5344

Public Health
P:(828) 250-5000
40 Coxe Avenue
Asheville, NC 28801

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Hours of Operation

Monday - Friday
8:00 a.m. to 5:00 p.m.

Mailing Address

Health & Human Services
PO Box 7407
Asheville, NC 28802

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