High Cost / High Risk Patients

Strong community leadership fights chronic illness

Nearly 70 percent of North Carolina’s Medicaid budget is consumed by high-cost and high-risk disabled and elderly clients with serious and co-morbid medical conditions. Recognizing this reality, the North Carolina General Assembly directed the N.C. Department of Health and Human Services in 2005 to “expand the scope of Community Care of North Carolina’s care management model to recipients of Medicaid and dually eligible individuals with chronic conditions and long-term care needs…” This effort began with nine networks piloting a chronic care model and creating a model for replication and adoption across the state.

Through its regional community-based health care infrastructure, Community Care has the framework to implement a comprehensive chronic care program that addresses many of the important elements identified by the MacColl Institute and Ed Wagner’s research on the chronic care model.

Community Care recognized the importance of strong community leadership in the development of a chronic care model. Local network leadership was challenged to convene new stakeholders and gain input and feedback into their expanded mission and strategies. Community resources were identified and integrated into the chronic care program and these new relationships and collaborations strengthened our chronic care model. For example, many of the networks developed relationships with the Aging, Disability and Resource Centers, with local organizations representing the elderly and disabled communities, and with home and community-based providers.


Successful chronic care programs must address the challenges associated with the chronically ill population, including:

  • The current health care delivery system is inherently fragmented and complex.
  • The primary care system has traditionally focused on acute problems.
  • Reimbursement and financial incentives are not aligned to promote the management of individuals with chronic conditions.
  • Team-based care, often because of reimbursement issues, does not occur as often as it should when managing individuals with chronic disease.

Designed to build upon Community Care’s established foundation, the chronic care initiative emphasized an enhanced care management processes with strong ties to the medical homes and built new connections with community-based long-term care providers and hospitals. Community Care partnered with those providers and other community professionals to improve how care is organized and delivered and to ensure accountability for managing target populations.

Targeted for this initiative are individuals who are eligible for Medicaid and who are in the aged, blind and disabled (ABD) or CAP-DA (Community Assistance Program for Disabled Adults) eligibility categories. A defined subset, such as those individuals with high cost, high utilization and/or high risk, is being targeted for comprehensive care management. In addition, enrollees who are dually eligible for both Medicaid and Medicare are eligible to participate on a voluntary basis.

By implementing a sophisticated model of care management – and by using effective evidence-based tools and systems – Community Care has demonstrated that it can improve health outcomes and access while containing Medicaid costs.