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 PublicHea 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 CommuniCare, 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.  

Cumberland County Health Department

Cumberland County Department of Social Services

At the Cumberland County Department of Public Health (CCDPH) and Department of Social Services (DSS), we have always been committed to improving the lives of individuals and families in our community. This program is in development and seeking community partners as well as developing standard operating procedures while taking preliminary referrals. This pilot program aligns with the efforts of NC Department of Health and Human Services to address the needs of the whole child and family by promoting collaboration across Cumberland County Departments. The primary goal of this program is to help improve the overall health of individuals and families in the Cumberland County community and create lasting change through collaborative efforts. 

The program is currently accepting referrals.  Referrals can be made through the UniteUs NCCare360 platform https://app.auth.uniteus.io/ or via email at connectedcareprogram@cumberlandcountync.gov.