2022-137-E-Health-Duke University - Charlene Wong-Federal awarding agency

Browse Search

NC Integrated Care for Kids Service Integration Coordinator Statement of Work Glossary Service Integration Coordinator (SIC); Integrated Care for Kids (InCK). Problem Statement The goal of the North Carolina Integrated Care for Kids Model (NC InCK) is to provide efficient, optimal physical and behavioral healthcare for children ages birth to 21 who receive services through North Carolina’s Medicaid or CHIP program. Children must live in one of five NC counties to enroll in NC InCK – Alamance, Durham, Granville, Orange or Vance. A Service Integration Coordinator (SIC) is an educated professional with an innovative mindset who provides strategic coordination of care management services so that child serving systems are aligned and identified children have a Single Plan of Care. A Service Integration Coordinator (SIC) should have experience in coordination of care activities, care management or case management. This role will be responsible for a range of care coordination support on behalf of children in the InCK model- and systems-level support to better integrate key services for children and families in InCK’s 5-county region. The SIC will also serve as a knowledgeable resource for the broader InCK team on the sector they represent (early childhood, child welfare, behavioral health, etc.) and serve as a proponent of InCK’s work to improve care coordination for children within their hiring institution. Through this role, the SIC will be an integral part of an interdisciplinary team of authorized clinicians, care managers, case managers, social service providers, and care givers, working to improve the health status and transitions of care to achieve optimal clinical and child well-being outcomes. Goals 1. During years NC InCK planning 2020 and 2021, the SIC staffed the hiring organization or agency will be onboarded to the NC InCK model and receive training on their roles. SICs will support model development through their expertise in their own sector as well as any relevant past experience. The on-boarding of SICs will be supported by the UNC National Implementation Research Network. 2. During the implementation period of the model (2022-2026), the SIC will perform the following activities: a. Identify, record and maintain relevant contact information and work with a Single Point of Contact for integrated care coordination or case management across healthcare and social services sectors for children requiring multiple services or who are at risk of out of home placement. b. Assist in the development of a Shared Action Plan for children with higher medical and social needs with common goals determined by families and key stakeholders supporting the family. Monitor services, make referrals and assess progress of children toward their Shared Action Plan goals. c. Use a patient-centric, collaborative partnership approach in all model activities. d. Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s). e. Electronically document all activity in relevant documentation systems. f. Communicate and coordinate with the child’s Single Point of Contact as needed to minimize fragmented care and foster appropriate utilization of services. g. Provide on-site, community, and telephonic outreach to families, providers, and community stakeholders to advance NC InCK model goals and supported initiatives (e.g., stakeholder or parental training programs). DocuSign Envelope ID: 7832B0E4-F34E-430E-A3C2-1A6A14F29307