Family Care Coordination Services

Care Management for High-Risk Pregnancies

Care management services are available to individuals who are pregnant or in their postpartum period who are enrolled in North Carolina Medicaid. In some counties, a limited number of uninsured individuals may also receive this service. Care managers are degreed social workers or registered nurses who work with you and your prenatal care provider to ensure you receive the best possible care while you are pregnant and after you deliver your baby. North Carolina has care managers based in your community. For more information about care management, call your local public health department
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Care Management for At-Risk Children

CMARC is a program offered at no charge for children birth to 5 years of age who:

    •  Have long term medical conditions; and/or
    • Are dealing with challenging levels of stress; and/or
    • Are referred by the child’s doctor When the care manager receives a referral, they will talk with you to determine whether your child and family could benefit from CMARC services.
    • For eligible families who want CMARC services, a CMARC plan of care is developed by the family and the CMARC care manager. CMARC care managers work with families through:
      • home visits
      •  phone calls
      •  visit the doctor with you
      •  other types of contacts.
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Advanced Medical Home Care Management

The North Carolina Department of Health and Human Services (DHHS) developed the Advanced Medical Home (AMH) program as the primary vehicle for delivering care management as the state transitions to NC Medicaid Managed Care. High-quality primary care with the capacity to manage population health is foundational to the success of North Carolina’s Medicaid Transformation, supporting the delivery of timely care in the appropriate setting to meet each Member’s needs.” Each month, the prepaid health plans (PHPs) within the managed care system sends Surry County Health Nutrition Center a list of enrolled patients and identifies those that may need additional resources or support. The Advanced Medical Home care manager then tries to connect with said patients to ensure all needs are being met within a timely manner. The Advanced Medical Home care manager assesses needs for social determinants of health, such as food, housing, safety and transportation, provides education for chronic medical problems, and assists with referrals for patients. These services typically go beyond what medical providers can assist with during office visits. The Advanced Medical Home care manager works closely with Surry County Health Nutrition Center’s primary care and pediatric clinics to ensure the highest quality of care is being given to our patients. (Source: Advanced Medical Home | NC Medicaid (ncdhhs.gov)Advanced Medical Home | NC Medicaid (ncdhhs.gov))

Behavioral Health

We provide behavioral health services for adults and children, including a designated ADHD clinic. Our Qualified Behavioral Health Professionals are certified in counseling, therapy, and other treatments for a broad spectrum of mental health concerns. This is an integrated program, and all of our care management programs can refer to to our behavioral health clinic.