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The Center for Community-Based Primary Care

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CCNC Foster Care

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CCNC Foster Care Program

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Children and youth in foster care face significant challenges in obtaining needed healthcare. Many come to foster care after suffering trauma and upheaval in their biological families. This often involves multiple relocations that can separate foster children from established relationships with primary care physicians and scatter their medical records. Maintaining continuity of care for this population is a particular challenge as is providing trauma-informed care that recognizes the high stress of the foster care experience.

CCNC has for decades worked with foster parents, public health agencies, departments of social services, medical associations and other stakeholders to help ensure this vulnerable population receives appropriate care.




Background on Community Care’s Foster Care Services

CCNC has provided statewide care management services to the Medicaid population for over twenty years, using the medical home primary care case management model.

CCNC began to focus more closely on foster care in 2010 by bringing together outside entities and internal staff to collaborate on developing information of best practices for children and youth in foster care in North Carolina. The aim was to help improve patient health outcomes and to reduce unnecessary utilization and the total cost of care. 

We worked collaboratively with the NC Pediatric Society program, Fostering Health NC, to provide education, training, and support to foster care stakeholders in our state. These groups included departments of social services, primary care providers, and foster parents. Our shared focus was on the American Academy of Pediatrics (AAP) recommendations for children and youth in foster care and the importance of care management for the foster care population.

In January 2020, CCNC rolled out a statewide, standardized model for children and youth in foster care. We extended the length of service periods to address the greater prevalence of chronic conditions in children and youth in foster care. CCNC employed Foster Care Coordinators and Foster Care Outreach Specialists to build and improve relationships with local departments of social services, primary care providers, LME-MCOs, and other stakeholders.

In February 2022, CCNC’s scope expanded to assist former foster youth nearing age 26 by facilitating transfer of their care to adult care providers, investigating insurance options, and sharing Healthcare Power of Attorney and Living Will information. At that time, we also implemented a foster care risk stratification method to identify and provide greater intensity of services for the higher risk populations and comprehensive supports around physical health, behavioral health, pharmacy, and social determinant of health needs.

CCNC currently collaborates with nearly 75 percent of DSS foster care units and all LME-MCOs. We share custody status notifications with primary care providers to inform them of their patients’ custody status and to provide the most updated caregiver and DSS contact information. 

Our process includes screenings and assessments to identify the level of service needed to help meet member-specific care goals related to physical health, behavioral health, oral health, medication concerns, and social determinants of health (such as food, transportation, housing, and interpersonal violence concerns).