Care Management for at Risk Children (CMARC)

Story Behind the Curve

We are limited per Care Impact/ Virtual Health regarding access to impact data. Data only goes back to May 2023.

Graduation is defined by client having met all goals. The goals are set by the care manager and the parent of enrolled child. CMARC has to have a preventative goal, safe sleep and a goal for whatever else you are working on with the family.

1. Preventative goal-Child to attend upcoming well child visit. We would have to assess any barriers any list them. The intervention could be the care manager assisted mom with scheduling the appointment or scheduling transportation for mom to attend.

2. Safe sleep goal-Mom to practice safe sleep barriers-intervention would be providing safe sleep education or connecting the family with cribs for kids.

3. NICU goal-to attend upcoming specialty appointments after discharged. Accesses barriers and interventions would be same as the preventative.

4. Goals can be graduated out once these measures are met consistently. However, it is important to remember that a child can have different goals, and the goals can be graduated at different times.

What We Do

CMARC Early Childhood Care Management is an at-risk population management program that serves children from birth to 5 years of age who meet the program’s risk criteria.

The goals of the program are:

To help ensure that children are raised in healthy, safe, and nurturing environments
To improve the care of children by linking them to services that will meet the needs of the child and family
To support children in reaching their developmental potential
Services provided by CMARC care managers are tailored to patient needs and risk stratification guidelines. Care Managers work with families through home visits, virtual visits, phone calls, community and hospital visits, and can even attend doctor’s appointments with families!

https://www.co.forsyth.nc.us/publichealth/child_service_coordination.aspx

Who We Serve

Who is Eligible?

Children with complex/chronic/long term medical conditions
Families dealing with challenging situations/social concerns
Recent hospital or NICU stay, or frequent ED usage due to chronic medical conditions
Foster Care placements

How We Impact

CMARC Care Managers help families get needed answers involving their child, offer referrals to community resources, provide information and education on various topics, and work to help families build strong links with their child’s doctors.

Progress in 2023

Specifically, CMARC became fully staffed at the end of 2023, which included a Nurse Care Manager to work specifically with the NICU follow up clinic and Amos Cottage which serves NICU graduates and medically /developmentally challenged infants and children.

CMARC is now fully staffed and fully trained which is a big benefit for meeting/improving state performance measures. We work hard to make sure we are following the CMARC standard guidelines. Contacting new referrals within 24-48hrs and timely documentation.

We also meet as a team to discuss complex cases and collaborate to make sure that we are linking the families with every possible resource to benefit the child's health and development. We have great relationships with the pediatric providers, hospital teams and community partners in Forsyth County that is a benefit when working with our community.

Progress in 2024

CMARC continues to be fully staffed, however, did have a nurse out several months on medical leave. The CMARC team worked hard to cover that nurse's assigned clients.

CMARC has seen an increase in referrals and continues to complete the outreach/engagement of those new referrals within a 24-48hr time frame. As a team CMARC continues to follow the CMARC standard guidelines to assure that all quality and quantity measures are met.

CMARC continues to collaborate as a team to discuss complex cases and build relationships with community partners. The CMARC team also serves the community by attending community events and participating in flu/vaccine clinics held by Forsyth County.

Progress in 2025

How Better Off

Percentage of CMARC population with a signed care plan within 30 days of referral

Dec 2024

97%

-2%

How Well

Percentage of families engaged in CMARC within 7 days of referral

Dec 2024

92%

-4%

How Well

Number of children who successfully complete the program

Dec 2024

134

28%