Medical Home Network Expands to North Carolina and Puts Patients at Center of NC Medicaid Reform

  • Published On  Jun 10, 2021

North Carolina Medicaid enrollees beginning July 1 will participate in managed care plans, the start of a person-centered program that will transform their health care. Community Health Centers (CHCs) acting as Tier 3 Advanced Medical Homes have adopted the proven care management model of Chicago-based Medical Home Network (MHN).

CHCs have accepted delegated responsibility to manage the care of more than 50,000 members who have chosen them as primary care providers.  Developed and refined over the past seven years, the MHN model uses practice-employed community health workers and care managers to screen and address social determinates of health, close gaps in care and coordinate health care services in a cost-effective manner that improves patient outcomes.

Proven Medical Home Model Enhances Care Management

On July 1North Carolina will join the more than two-thirds of states that have transitioned from a fee-for-service system to Medicaid managed care. In contrast to fee-for-service, which is pay based on the number and type of healthcare services performed, managed care reform gives providers incentives to improve individual member and population health outcomes while reducing low-value care.

MHN is helping to develop the care management program for the Carolina Medical Home Network, a collaborative of 24 federally qualified health centers (FQHCs) that provide in-network care for health plans across North Carolina. NCCHCA is the collaborative's sponsor and managing partner.

"MHN's substantial results in seven years of working with Chicago area FQHCs were decisive in forming the alliance," said NCCHCA President Chris Shank.

"We believe care management is most effective when delivered by the medical home and has the potential to address health disparities facing the low-income populations we serve," Shank said. "Medical Home Network's care coordination protocols show a respect for diverse needs and cultures and will help our patients and their families better able to manage their health."  

The MHN care management model includes National Committee for Quality Assurance (NCQA) accreditation.

"We have documented success in establishing a high-value system of care for the Medicaid population in Chicago, and now other safety net providers are eager to learn from that experience," said MHN Chief Medical Officer Dr. Art Jones. Risk-adjusted key indicators that the model improves care and reduces costs include:

  • $81 million cost savings over 5 years.
  • 36% decrease in inpatient hospital days per 1,000 patient years.
  • 27% decrease in admissions per 1,000 patient years.
  • 12% drop in readmissions.
  • 47% increase in follow-up with patients after an emergency room visit.
  • 10% increase in visits to a primary care physician.

For the Chicago Medicaid population, MHN has developed an evidence-based health risk assessment (HRA) tool that reveals social determinants of health predictive of future hospital utilization and cost. Newly assigned members are screened within 60 days of enrollment.  MHN's HRA completion rate is 89%, Jones said, far outpacing that achieved by health plans who centralize care management internally.

That information is combined with several other data sources and then analyzed using artificial intelligence to identify members who are most likely to benefit from intensive care management.  The care plans give primary care doctors a clear view of patients' immediate and long-term needs.

Now MHN is ready to help North Carolina CHCs achieve successful outcomes.

"We're thrilled to expand our mission outside Chicago," said MHN President and CEO Cheryl Lulias. "The success we've seen and the lessons we've learned are replicable and can help primary care associations in other states meet their goals surrounding care transformation for the Medicaid population."

Care Coordinators, Care Managers Put Families First

Managed care reform integrates physical health, behavioral health and pharmaceutical services under one plan. MHN is helping the North Carolina collaborative set up policies and procedures, train staff and negotiate contracts with insurers to prepare for the launch of the NC Medicaid Standard Plan.

After sharing, modifying and teaching its managed care protocols, MHN will stay on for 18 months after the July launch to mentor care teams. The tools, approaches and training are based on the Chicago model, but tailored to North Carolina needs. MHN leaders will work together with the FQHCs to determine how to best improve outcomes for health plan members.

For some patients, the new system will be their first medical home experience. Patients under the MHN model build face-to-face relationships with a professional who is coordinating their care, identifying and respecting the wishes of patients and their families.

Care coordinators, people from patients' communities hired and trained to help bridge language and cultural gaps, connect health plan members to resources available under their Medicaid coverage. Care management teams collaborate with specialists, behavioral health providers and hospitals to share the care plan, avoid duplication of services, reduce medical errors and improve the patient experience.

In addition to simplifying care and avoiding duplication, North Carolina's managed care reform will give clinicians incentives to focus on preventive care and find creative solutions for engaging low-income patients in their long-term care plan.

About Medical Home Network

Medical Home Network is dedicated to transforming care and building healthier communities by enhancing care coordination and quality, improving access and reducing fragmentation and cost. MHN starts by building partnerships in the community to connect people with the care and support they need from comprehensive primary care to community-based organizations. MHN care teams build trusted relationships with patients and coordinate care with a focus on whole person health. The MHN model of care is powered by technology that connects different healthcare entities and enhances collaboration. This approach is improving outcomes, lowering costs and reducing health disparities. Learn more about their mission at and on LinkedIn at