Medical Homes: Local Focus, Better Health

As policymakers across the country look to balance their budgets, some are turning to Medicaid, recycling the same harmful policies they’ve used year-after-year: eliminating coverage for vulnerable Americans, restricting critical benefits like prescription drug coverage, imposing premiums on those who can’t afford them, and slashing already-low provider reimbursement rates.

Community Catalyst and Georgetown University Health Policy Institute Center for Children and Families created the States of Innovation blog series to shine a spotlight on states that are trying to find a better way. We will highlight states that are pioneering new approaches to making Medicaid more sustainable without harming – and often by improving – care for the millions of vulnerable seniors, people with disabilities, children and low-income parents that rely on Medicaid.


For the most vulnerable populations, the health care system can be a maze leading not to better health, but to fragmented, costly, and inefficient care. By providing care management and creating a strong health care delivery infrastructure at the community level through a medical home program, North Carolina has made remarkable strides in improving quality and continuity of care and improved health for Medicaid beneficiaries while significantly reducing costs. For example, Community Care of North Carolina (CCNC), North Carolina’s medical home program created a statewide diabetes initiative that has improved the health of diabetes patients through improved glucose, blood pressure, and cholesterol control. Between 2000 and 2002, CCNC’s diabetes management program is estimated to have saved $2.1million.

Jasmine’s story helps illustrate what is happening behind those numbers. Jasmine is a North Carolina teen with diabetes. Her mom knew that as her daughter was entering middle school it was very important that she develop the skills to manage her illness. The American Diabetes Association hosts summer camps to provide kids with the skills and confidence they need to manage their own care. Jasmine’s mom didn’t have the money to send her to camp, but through CCNC, Jasmine’s nurse care manager identified scholarships that allowed Jasmine to attend the camp. By providing health care, facilitating access to community resources and empowering people to be active partners in their health care, North Carolina is improving health and quality of life while reducing costs for Jasmine’s family as well as thousands of other families like them.

To find out more about how CCNC works, including Jasmine’s story, you can view this video produced by the Ash Institute at Harvard’s Kennedy School of Government.

What is North Carolina Doing? CCNC is a statewide public-private partnership that serves more than 1.2 million Medicaid beneficiaries as well as 70,000 low-income, uninsured residents. The state’s 100 counties are organized into 14 health networks, and within these health networks there are approximately 1,500 medical homes, 4,300 providers, and 600 care managers statewide.

Through CCNC’s extensive care management services, CCNC strives to improve health by ensuring access to care and community services. The CCNC care managers identify which enrolled members will benefit most from care management services, develop individualized care plans, provide health education and guidance on self-management of illness, facilitate positive relationships with and link patients to community services, plan and coordinate transitional care, and, when appropriate, make home and hospital visits. As Jasmine’s story illustrates, the work that the medical homes are doing extends well beyond the exam room.

CCNC has invested providers with ownership of the program, thereby engaging them in the process of health improvement and through partnerships with community resources and other community physicians. CCNC has created a strong network of support for the patients.

While support and a basic framework are provided at the state level, CCNC has found that health can be improved more concretely through the empowerment of patients and engagement of providers at the local level. CCNC has developed statewide health improvement initiatives, but they are flexible enough to meet the specific needs at the network or community level. Further, because the networks are better positioned than the state to understand the specific needs of their communities, networks are able to develop their own health initiatives to address regional health issues.

What Results Has North Carolina Achieved? Despite the increasing enrollment of people with severe chronic physical and mental health concerns, CCNC has accomplished a variety of health improvements, including:

  • • a dramatic decline in emergency room use and preventable hospital admissions
  • • improvements in testing for and control of cholesterol, blood pressure, and diabetes that exceed national benchmarks
  • • a significant decrease in asthma-related hospitalizations
CCNC has not only improved the quality of care and the health of patients, but has also provided significant savings to North Carolina and its taxpayers. Within its first years, CCNC was already achieving a savings of more than $100 million per year. An independent audit estimates that between 2007 and 2009 CCNC saved nearly $1.5 billion.

Continued expansion of CCNC programs may help the state to reap even more savings and provide higher quality care to more people. North Carolina is one of 15 states that received a planning grant from the Centers for Medicare & Medicaid Innovation to improve care for those who are enrolled in both Medicare and Medicaid (dual eligibles). As part of these integration efforts, the state is proposing to expand the CCNC medical home program to all eligible duals, which would provide medical home services for duals in all types of living situations, including nursing homes. Strong emphasis is placed on improving the engagement and input of beneficiaries and their caregivers.

What Can Other States Do? With the passage of the Affordable Care Act (ACA), many states are looking to create or expand patient-centered medical homes or implement the ACA Health Homes Option. The Health Home Option in the ACA offers states an excellent opportunity to take advantage of increased federal matching funds to build a system, like North Carolina’s, that provides tangible improvements in health and wellbeing for Medicaid patients.

CCNC has been working for many years to develop the program into what it is today and other states cannot be expected to implement a program of this size or scope immediately. But states can start with smaller programs, and then invest those savings into expanding the program over time. CCNC’s efforts provide a sense of what can be achieved through a commitment to continuous program improvement.

-Siobhan Brown, Medicaid Policy Intern