At-Risk Population Management for Children Birth to 5 Years of Age
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.
Services provided by CC4C care managers are tailored to patient needs and risk stratification guidelines. A comprehensive health assessment, including the Life Skills Progression1, assists the care manager in identifying a child’s needs, plan of care and frequency of contacts required. Contacts occur in medical homes, hospitals, in the community and in children’s homes.
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. CC4C staff also work in close collaboration with their local CCNC networks to access care management histories, Medicaid claims and other vital records, and to coordinate care management services. CCNC networks also assist in quality improvement and in evaluating program effectiveness.
- Children with Special Health Care Needs (chronic physical, developmental, behavioral or emotional conditions) who require health and related services of a type and amount beyond that required by children generally
- Children exposed to severe stress in early childhood, including:
-- Extreme poverty in conjunction with continuous family chaos
-- Recurrent physical or emotional abuse
-- Chronic neglect
-- Severe and enduring maternal depression
-- Persistent parental substance abuse
-- Repeated exposure to violence in the community or within the family
- Children in foster care who need to be linked to a Medical Home
- Children in neonatal intensive care needing help transitioning to community/Medical Home care
- Children with “potentially preventable” hospital costs identified under methodology developed by Treo Solutions, Inc.
A CC4C Workgroup meets monthly to advise and guide the work of CC4C. The group includes representatives from the NC Division of Public Health (CC4C and Early Intervention), NC Division of Medical Assistance, CCNC, the physician community, local health departments and members of the DPH Children and Youth Family Council.
1. The Life Skills Progression is a tool that measures a parent’s life skills (the abilities, behaviors and attitudes) that help a family achieve a healthy and self-sufficient level of functioning. The tool assesses 35 dimensions that look at relationships/support systems; education and employment; health and medical care, mental health and substance use/abuse and access to basic essentials. The LSP also assesses the child’s developmental progress. When completed sequentially in 6-month increments, the LSP makes progress visible and measurable.