Integrated Care — Population Health Program

AmeriHealth Caritas North Carolina's Population Health program utilizes a person-centered approach that listens to and respects Member and family choices, including cultural, spiritual, and linguistic preferences. There are six core components of the program. We appreciate your assistance in letting our members know about these components and informing us if any of our members could benefit from this additional support.

The Rapid Response and Outreach Team (RROT) operates a call center that assists members with urgent or short-term needs — such as transportation or accessing medical supplies — and helps members navigate the health care system and address barriers to care, such as transportation and language challenges. Providers are also encouraged to call the RROT when they have a member in need of assistance. Below are some of the other functions of the team:

  • Receiving inbound calls from members and providers.
  • Conducting outreach activities.
  • Conducting Care Needs Screenings and Social Determinant of Health (Opportunities of Health) screenings.
  • Providing care coordination support to address barriers to care.
  • Coordinating value added services.

Members and providers may request Rapid Response and Outreach Team support by calling 1-833-808-2262.

Pediatric preventive health care intervention is designed to improve the health of members younger than 21 years by increasing adherence to Early Periodic Screening, Diagnosis and Treatment (EPSDT) guidelines. We identify and coordinate preventive services for these members, especially when a member is due or overdue for an EPSDT service.

The Bright Start Program works to improve birth outcomes and reduce the incidence of pregnancy-related complications through early prenatal education and intervention. Bright Start prenatal nurse care managers help to facilitate access to needed physical and behavioral health care services for both mom and baby.

Members enrolled in the Bright Start Program receive a variety of interventions depending upon the assessed risk of their pregnancy (PDF) and/or newborn post-delivery. The Bright Start team will outreach to help ensure member follow-up with medical appointments, identify potential barriers to getting care, and coordinate member access to needed resources in the community.

Addresses members' health care needs while assessing for and addressing social needs and barriers and providing hands-on coordination. Care Managers and Care Connectors identify opportunities for health and connect members to needed health care and community-based services.

Serves high-risk members identified as needing comprehensive and condition-specific assessments, and re-assessments along with the development of person-centered goals with a focus on prevention. CCM promotes quality cost-effective outcomes according to evidence based practice and clinical guidelines for specific clinical conditions.

The purpose of Transitional Care Management is to provide a safe transition for members moving from one clinical setting to another in order to prevent unplanned or unnecessary readmission and/or emergency department visits, or adverse outcomes such as hospital to home or nursing home to home.

For members with LTSS needs, this includes moving from a nursing facility or other institution. Discharge planning begins at time of admission. Members at risk for readmission or other poor outcomes are assessed and contacted for further interventions.