The Connected Care Program (CCP) is a partnership between the Cumberland County Department of Public Health and the Department of Social Services. It helps families and individuals in need by addressing issues that affect their health, like housing, food, and unemployment.

The program has teams made up of case managers, health educators, and social workers who work with people to improve their health and well-being. These teams, including a nurse and a nutritionist, offer support in person, over the phone, or online. They help people with healthcare needs, applying for food assistance (like food stamps), Medicaid, childcare help, and other services.

The CCP works with families and individuals until their health and living situation improve. Anyone living in Cumberland County can get help through the program. Referrals can be made online through UniteUs (NCCARE 360) or by email.

In 2022, the North Carolina Department of Health and Human Services (NC DHHS) restructured and created the Division of Child and Family Well-Being to help achieve its vision of children who are healthy and who thrive in safe, stable, and nurturing families, schools, and communities.  

The new division brought together programs and staff currently operating across multiple department divisions that support the physical, behavioral, and social needs of children under one division. This pilot proposal aligns with the efforts of NC DHHS to address the needs of the whole child and family by promoting collaboration across Cumberland County Departments. This proposed pilot is a collaboration between the Department of Social Services (DSS) and the Cumberland County Department of Public Health (CCDPH) which focuses on primary prevention by utilizing a whole person/family approach and addressing social determinants of health (SDOH). 

The Department of Social Services and the Health Department will create a three-year pilot program with three (3) teams responsive to community referrals to provide care coordination and case management services in an effort to:  

• Address social determinants of health (food insecurity, housing instability, lack of transportation, employment, access to medical care, education, well-being, and interpersonal violence)   

• Address social needs  

• Improve health behaviors and health outcomes  

• Improve health equity and reduce health disparities  

• Reduce preventable hospital stays  

• Prevent and reduce child abuse and neglect  

The three-year pilot includes the development of three (3) Case Management and Care Coordination Teams. Each team will include a Public Health Educator II, a Case Manager, and a Community Social Services Assistant (CCSA) paraprofessional. The teams will also receive support from a Nutritionist II a Public Health Nurse II, and a Lead Worker (Income Maintenance Caseworker). The staff members will be supervised by an Administrative Officer II and Social Worker Supervisor II.  

Each team will provide case management and care coordination services in-person (in home and office), by telephone or virtually. Proposed services include follow up on healthcare discharging plan, coordination of public health and healthcare with external providers and assistance with linkage to community resources for health care, housing, education, employment, and legal issues. Staff will support individuals and families in their enrollment to DSS economic services. This includes FNS (food stamps), Medicaid, childcare subsidies, and energy and water assistance. Teams will provide hands on support families for families the in implementation of case management plans. For example, assisting families in the grocery store, transportation to healthcare visits, and follow up with pharmacies.  

Each team will have an active caseload of approximately 30-35 families. Individuals and families referred will participate in an appropriate consent process.  Education materials shared with patients will consider health literacy and diversity, equity, and inclusion. Teams will also participate in community outreach events. Staff will use a team-based, person-centered approach to case management.  

The teams will operate on a referral basis. Key referral sources include:  

• CCDPH patients and clients  

• Medicaid Transformation Requirement: CCDPH staff screen patients for SDOH to identify patient needs. Utilize NCCARE360 to refer patients to resources. Connect patients to CCDPH Social Worker for coordination of resources  

• Stedman Wade Health Services and Cumberland HealthNet patients seen at Health Department, as available  

• Screened out CPS intakes 

• High risk school systems (schools that have a high CPS referral rate) 

The proposed project will create fourteen (14) new FTE positions integrated into the DSS and CCDPH organizational structure for case management and care coordination.  

In addition, the pilot will support two (2) new Social Worker III positions to provide intake, information, and referral to DJJ court to find alternatives to delinquent children coming into the foster care program. Services would include collaboration with Community Care, Juvenile Detention, Alliance for authorization of placement, Voluntary Placement Agreement (VPAs) to place children temporarily until services are in place, which include physicals, mental health treatment, etc.  

In 2023, the Connected Care Program (CCP) was established as a pilot initiative between the Department of Social Services and the Department of Public Health. The program was created to improve overall health outcomes and quality of life for residents in Cumberland County by addressing social determinants of health that directly impact well-being.

CCP assists and educates individuals and families experiencing challenges related to health concerns, food and housing insecurity, unmet social and emotional needs, transportation barriers, and unemployment. Referrals are received through multiple access points, including NCCARE360, community partners, walk-ins, outreach events, phone calls, and email. Once referred, the CCP team provides case management services to connect residents to appropriate community resources and support.

As the program’s launch year, 2023 was primarily focused on infrastructure development and staffing. Significant effort was dedicated to hiring and onboarding team members to ensure adequate capacity to meet program demands. During this foundational year, the program received 133 referrals, and clients began receiving coordinated support services.

While referral numbers were modest compared to subsequent years, 2023 laid the groundwork for program growth by establishing workflows, defining roles, building interdepartmental collaboration, and strengthening referral pathways. This investment in staffing and infrastructure positioned the Connected Care Program for expanded outreach, increased referrals, and measurable growth in 2024.

In 2024, the Connected Care Program entered its second full year of implementation with an established and fully functioning team. During this year, referrals increased significantly from 133 in the previous year to 250, representing an 88% increase in program utilization. This upward trend reflects growing community awareness, improved internal referral workflows, and strengthened trust in the program’s ability to connect individuals and families to essential services.

Throughout 2024, the CCP team expanded its outreach efforts by participating in a greater number of community events, health fairs, and partner-led initiatives. These outreach activities enhanced visibility of the program and directly contributed to increased referrals. In addition, the team strengthened partnerships with a broader network of community agencies, which improved cross-sector collaboration and streamlined referral pathways for residents seeking rent/utility assistance, transportation support, and other critical resources.

The combination of strategic outreach expanded partnerships, and a more coordinated internal process contributed to measurable growth in referrals and positioned the Connected Care Program for continued expansion and impact in 2025 and beyond.

In 2025, the Connected Care Program entered its third year with continued expansion, stronger community visibility, and increased service utilization. Total referrals increased from 250 in 2024 to 295 in 2025, demonstrating sustained program growth and a continued upward trend in community engagement.

A major contributor to this growth was expanded outreach and partnership development. The CCP team participated in 33 outreach events throughout the year, increasing program awareness and strengthening relationships with community agencies, healthcare providers, and local organizations. These efforts enhanced referral pathways and improved coordination of services for residents.

In addition to increased referrals, 2025 reflected meaningful growth in direct support services that address social determinants of health:

• 17 Instacart memberships were provided to clients to improve food access and reduce transportation-related barriers to obtaining groceries.

• 105 bus passes were distributed (85 thirty-day passes and 20 one-day passes), supporting access to medical appointments, employment, and essential services.

• 80 Uber Health ride requests were coordinated, further expanding transportation solutions for residents with limited mobility or urgent healthcare needs.

These increases indicate not only higher program utilization, but also a deeper level of case management engagement and responsiveness to client needs. The data reflects CCP’s growing capacity to address transportation and food insecurity barriers that directly impact health outcomes.

Overall, 2025 demonstrates continued positive momentum, expanded service delivery, and strengthened community integration. Moving forward, maintaining strong outreach efforts, monitoring service utilization trends, and evaluating impact on client outcomes will be key to sustaining and scaling program success.