Publications and Reports

Performance data and analysis

Providing access to quality health care while restraining cost is the cornerstone of the Community Care program. CCNC reports and analyses examine what we are doing to improve the health of the Medicaid population in North Carolina and how these efforts are paying off. 

The Enhanced Primary Care Case Management System Legislative Report provides the N.C. General Assembly with quarterly updates on our work. The report summarizes the results of CCNC's latest program initiatives and provides risk-adjusted analyses of acuity levels and cost trends of the CCNC-enrolled population. Through the Informatics Center, CCNC also collects and analyzes Medicaid cost and utilization data on a regular basis.  A quick overview of CCNC's "vital stats" is available through the Medicaid Measures Dashboard compiled by the NC Department of Health and Human Services.

Disease and care management measures

Community Care has developed quality improvement and care management initiatives that achieve access, quality, utilization, and cost objectives by improving the management of patient care.  These initiatives aim to assess the needs and severity of their enrolled population in order to target care and disease management initiatives where they are most beneficial.   Overviews on these programs can be found under Population Management.  Reports of clinical measures are available below.

  • Assuring Better Child Health and Development Project

    Setting the Stage for Success: Implementation of Developmental and Behavioral Screening and Surveillance in Primary Care Practice—The North Carolina Assuring Better Child Health and Development (ABCD) Project

  • Collaborative Accountability for Care Transitions: The Community Care of North Carolina Transitions

    Collaborative Accountability for Care Transitions: The Community Care of North Carolina Transitions Program C. Annette DuBard, Jennifer Cockerham, Carlos Jackson N C Med J. 2012;73(1):34-40

  • Computed Tomography Utilization in NC Medicaid Population with a Focus on "High Exposure" Patients

    Lauren M. B. Burke, Holly Biola, Linda Grey, Rita M. Lahlou, Randall M. Best, Richard C. Semelka

  • Developing Community Consensus Regarding the DManagement of Attention-Deficit/Hyperactivity Disorder

    A Process for Developing Community Consensus Regarding the Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder

  • Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician

    Pediatrics 2012;129;e224; originally published online December 26, 2011

  • Heterogeneity in the Quality of Care for Patients with MCC by Psychiatric Comorbidity

    Cancer screening and single-disease quality measures may provide a benchmark for overall quality of care for persons with MCC; these measures were generally lower among persons with MCC and mental illness.

  • Incorporating Recognition of Depression Into Pediatric Pract

    Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice

  • Making It Local: Beacon Communities Use Health Information Technology to Optimize Care Management

    The 17 communities receiving funding from the Office of the National Coordinator for Health Information Technology through the Beacon Community Cooperative Agreement Program are leaders in building and strengthening their health information technology (health IT) infrastructure to provide more effective and efficient care management.

  • Mental Health Competencies for Pediatric Primary Care

    Pediatrics Vol. 124 No. 1 July 1, 2009 pp. 410 -421 (doi: 10.1542/peds.2009-1061)

  • Monitoring Side Effects with Antipsychotics

    "Monitoring Metabolic Side Effects when Initiating Treatment with Second-Generation Antipsychotic Medication"; Journal of Clinical Schizophrenia & Related Psychoses; Ellen Weissman, Carlos Jackson, Nina Schooler, Ray Goetz and Susan Essock ISSN 1935-1232 (Print); Issue Volume 5, Number 4 / January 2012; Pages 201-207; DOI 10.3371/CSRP.5.4.4; Online Date: Monday, December 19, 2011 Online at

  • News and Observer -- CCNC saves NC Medicaid $1B

    Insider item on release of Milliman study showing significant savings achieved by CCNC from 2007 through 2010.

  • Patient Requests for Office-Based Imaging

    The rising cost of health care affects our economy and can impact the health of our citizens. Costs can be divided into direct costs, which are incurred in the provision of services and procedures, and ancillary costs, such as labs and imaging. While ancillary services greatly assist providers in diagnosing and treating medical conditions, they can be overused or inappropriately used and can lead to adverse events. All providers should work to order the most appropriate imaging and tests and to protect patients at all times.

  • Prevention and treatment of childhood obesity

    Prevention and treatment of childhood obesity: care received by a state medicaid population. Lazorick S, Peaker B, Perrin EM, Schmid D, Pennington T, Yow A, Dubard CA. Clin Pediatr (Phila). 2011 Sep;50(9):816-26. PMID: 21525083

  • Report to the NC General Assembly - January 2011

    Overview of CCNC operations and results.

  • Seattle Times children denied care -- June 15, 2011

    Media coverage of study showing lack of access to care for Medicaid beneficiaries in Cook County, IL. The study is available here:

  • Use of Medical Homes by Patients with Comorbid Physical and Severe Mental Illness

    Patients with comorbid severe mental illness (SMI) may use primary care medical homes differently than other patients with multiple chronic conditions (MCC).

  • Using admin data to ID gaps in MH treatment

    Use of Administrative Data to Identify Potential Service Gaps for Individuals With Serious Mental Illness Smith T, Appel A, Donahue S, Essock S, Jackson C, Karpati A, Marsik T, Myers R Psychiatric Services 62:1094–1097, 2011 Available online at

  • With "Big Data" Comes Big Responsibility

    Holly Biola, Randall M. Best, Rita M. Lahlou, Lauren M. B. Burke, Charles Dewar, Carlos T. Jackson, Joshua Broder, Linda Grey, Richard C. Semelka, Allen Dobson

  • ABC: Medicaid children denied care - June 16, 2011

    Coverage of NEJM study on access to care in Cook County, IL

  • Auditing Medicaid access to specialty care

    Auditing Access to Specialty Care for Children with Public Insurance J. Bisgaier and K.V. Rhodes N Engl J Med 2011; 364:2324-33

  • Integration in action: 4 int'l studies

    Report by Nuffield Trust July 2011 Rebecca Rosen, R; Mountford, J.; Lewis, G; Lewis, R.; Shand, J. and Shaw, S. Available online:

  • Management of Cardiovascular Risk in Medicaid

    Management of cardiovascular risk in the usual care of medicaid recipients. Dubard CA, Schmid D, Bostrom S, Yow A, Viera AJ, Huston S, Lawrence W. J Health Care Poor Underserved. 2011;22(3):772-90. PMID: 21841278

  • News and Observer budget coverage - May 22, 2011

    Coverage of North Carolina's budget woes included information on CCNC's challenging saving goal.

  • Nonprofit changes name - April 15, 2011

    Access III of the Lower Cape Fear is now Community Care of the Lower Cape Fear.

  • Self-management to improve hypertension

    Bosworth HB, DuBard CA, Ruppenkamp J, Trygstad T, Hewsin DL, Jackson GL. Evaluation of a Self-management Implementation Intervention to Improve Hypertension Control Among Patients in Medicaid. Translational Behavioral Medicine: Practice, Policy and Research.

  • Building regional integrated delivery systems

    Community Care of North Carolina: Building regional integrated delivery systems that support the Medical Home Trygstad, T; Rice, K; Robinson, T; Pfeiffenberger, T; Coker, H; Roberts, N; Tong, G; Arrington, D; Williams, N; Bujold, E; McKee, J; Lancaster, M; Viracola, C; NC Pharmacist Vol. 91, Number 1: Vol. 91, Number 1; Winter 2011: 6-17 Online at

  • CCNC Sitemap

    Overview of the structure of

  • News and Observer Medicaid costs Feb 18, 2011

    CHAPEL HILL Gov. Bev Perdue and the General Assembly face the unenviable task of patching up a budget with a $2 billion-plus hole in it. High on the chopping block: Medicaid, the state's second-largest expense.

  • Racial Disparities in Blood Pressure Control

    Downie DL, Schmid D, Plescia M, Huston S, Bostrom S, Lawrence WW, DuBard CA. Racial Disparities in Blood Pressure Control are Unexplained by Treatment Differences in a Medicaid Population. Preventing Chronic Disease.

  • BP above goal in Medicaid population

    Viera AJ, Schmid D, Bostrom S, Yow A, Lawrence WW, DuBard CA. Level of Blood Pressure above Goal and Clinical Inertia in a Medicaid Population. J Am Soc Hypertension. 2010 Sep-Oct;4(5):244-54.

  • Jones Receives Harris Award - October 26, 2010

    The recipient of this year’s T. Reginald Harris Memorial Award isdescribed by his colleagues as “a giant in medicine in North Carolina.” J

  • Evolving Models of Behavioral Health Integration

    Evolving Models of Behavioral Health Integration in Primary Care Chris Collins, Denise Levis Hewson, Richard Munger, and Torlen Wade Milbank Memorial Fund Report May 2010

  • Prior Authorization - Physician-friendly Alternative

    A physician-friendly alternative to prior authorization for prescription drugs. Wegner SE, Trygstad TK, Dobson LA Jr, Lawrence WW Jr, Steiner BD. Am J Manag Care. 2009 Dec 1;15(12):e115-22.

  • CCNC in AMA News August 2, 2010

    Overview of CCNC and Medical Home model

  • Medical homes for children with asthma

    Enhancing the medical homes model for children with asthma. Domino ME, Humble C, Lawrence WW Jr, Wegner S. Med Care. 2009 Nov;47(11):1113-20.

  • Long-term Care Polypharmacy Initiative

    Analysis of the North Carolina long-term care polypharmacy initiative: a multiple-cohort approach using propensity-score matching for both evaluation and targeting. Trygstad TK, Christensen DB, Wegner SE, Sullivan R, Garmise JM. Clin Ther. 2009 Sep;31(9):2018-37.

  • North Carolina Medical Review - CCNC issue

    May/June 2009 issue of NC Medical Review dedicated to CCNC's operations and people. (Note: also available online in the archives of

  • Racial/ethnic differences in care

    Racial/ethnic differences in quality of care for North Carolina Medicaid recipients. DuBard CA, Yow A, Bostrom S, Attiah E, Griffith B, Lawrence W. N C Med J. 2009 Mar-Apr;70(2):96-101.

  • Estimated savings telephone consultations

    Estimated savings from paid telephone consultations between subspecialists and primary care physicians. Wegner SE, Humble CG, Feaganes J, Stiles AD. Pediatrics. 2008 Dec;122(6):e1136-40.

  • Cancer screenings for Medicaid recipients 50+

    Recommendation for and receipt of cancer screenings among medicaid recipients 50 years and older. DuBard CA, Schmid D, Yow A, Rogers AB, Lawrence WW. Arch Intern Med. 2008 Oct 13;168(18):2014-21.

  • NC's ABCD project

    Setting the Stage for Success: Implementation of Developmental and Behavioral Screening and Surveillance in Primary Care Practice --The North Carolina Assuring Better Child Health and Development (ABCD) Project DOI: 10.1542/peds.2006-0475 Pediatrics 2006;118;e183 Marian F. Earls and Sherry Shackelford Hay

  • NC Medicaid: Payer-Practice Collaboration

    Bodenbeimer T. North Carolina Medicaid: A Fruitful Payer-Practice Collaboration Ann Fam Med 2008:292-294

  • Improving Care through Community Networks

    Steiner BD, Denham AC, Ashkin E, Newton WP, Wroth T, Dobson LA, Jr. Community care of North Carolina: improving care through community health networks. Ann Fam Med. 2008;6(4):361-7

  • CCNC and medical home approach to kidney disease

    DuBard CA and Cockerham J. Community Care of North Carolina and the Medical Home Approach to Chronic Kidney Disease. NC Medical Journal, May-June 2008; 69(3): 229-32.

  • Longitudinal study screening ABCD practices

    Earls MF, Andrews JE, Hay SS. A longitudinal study of developmental and behavioral screening and referral in North Carolina's Assuring Better Child Health and Development participating practices. Clin Pediatr (Phila). 2009 Oct;48(8):824-33. Epub 2009 Jul 1.

  • Palivizumab - claims vs. medical data

    Reliability of Medicaid claims versus medical record data: in a cost analysis of palivizumab. Jacobson Vann J, Feaganes J, Wegner S. Pharmacoeconomics. 2007;25(9):793-800.

  • Proactive health managing with HIE

    Lobach DF, Kawamoto K, Anstrom KJ, Kooy KR, Eisenstein EL, Silvey GM, Willis JM, Johnson F, Simo J. Proactive population health management in the context of a regional health information exchange using standards-based decision support. AMIA Annu Symp Proc. 2007 Oct 11:473-7.

  • GI and practice-based QI

    Effectiveness of a practice-based, multimodal quality improvement intervention for gastroenteritis within a Medicaid managed care network. Zolotor AJ, Randolph GD, Johnson JK, Wegner S, Edwards L, Powell C, Esporas MH. Pediatrics. 2007 Sep;120(3):e644-50.

  • Medicaid ED for immigrants

    Trends in emergency Medicaid expenditures for recent and undocumented immigrants. DuBard CA, Massing MW. JAMA. 2007 Mar 14;297(10):1085-92. Erratum in: JAMA. 2007 Apr 25;297(16):1774.

  • Medicaid beneficiary perceptions of patient portal

    Lobach DF, Willis JM, Macri JM, Simo J, Anstrom KJ. Perceptions of Medicaid beneficiaries regarding the usefulness of accessing personal health information and services through a patient Internet portal. AMIA Annu Symp Proc. 2006:509-13

  • Academic health centers and family medicine

    Newton WP, DuBard CA. Shaping the future of academic health centers: the potential contributions of departments of family medicine. Annals of Family Medicine. 2006 Sept-Oct; 4 Suppl 1:S2-11.

  • Evaluation of product switching for loratadine OTC

    Evaluation of product switching after a state Medicaid program began covering loratadine OTC 1 year after market availability. Trygstad TK, Hansen RA, Wegner SE. J Manag Care Pharm. 2006 Mar;12(2):108-20.

  • Results from NC polypharmacy initiative

    Pharmacist response to alerts generated from Medicaid pharmacy claims in a long-term care setting: results from the North Carolina polypharmacy initiative. Trygstad TK, Christensen D, Garmise J, Sullivan R, Wegner S. J Manag Care Pharm. 2005 Sep;11(7):575-83.

  • Optimizing drug therapy for nursing homes

    A pharmacy management intervention for optimizing drug therapy for nursing home patients. Christensen D, Trygstad T, Sullivan R, Garmise J, Wegner SE. Am J Geriatr Pharmacother. 2004 Dec;2(4):248-56.

  • Direct cost analyses of palivizumab treatment

    Direct cost analyses of palivizumab treatment in a cohort of at-risk children: evidence from the North Carolina Medicaid Program. Wegner S, Vann JJ, Liu G, Byrns P, Cypra C, Campbell W, Stiles A. Pediatrics. 2004 Dec;114(6):1612-9.