The Atrómitos Way

#054: Innovations on the Ground: Building a Social Care Network

• Atrómitos, LLC

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Healthcare often focuses on clinical symptoms and medical treatments, while many patients lack essential support for non-medical factors which greatly affect health outcomes. Social care networks aim to connect healthcare providers with community-based organizations to address the social determinants of health, such as housing stability, food security, transportation, and access to medical care.

From early 2022 to mid 2025, Community Care Lower Cape Fear (or CCLCF) saw firsthand what coordinated care can accomplish—and what happens when funding disappears overnight. On today’s episode, Atrómitos president, founder, and CEO Michealle Gady speaks with two leaders at CCLCF who are driving the efforts to build a robust and sustainable social care network with a new grant from the New Hanover Community Endowment.

Michealle Gady has more than 20 years of experience helping health and human service providers, government agencies, advocates, and philanthropies create lasting community change.

Sarah Ridout, MBA, SPHR is the Director of Community Programs for Community Care of the Lower Cape Fear (CCLCF) where she focuses on planning, implementation and program oversight of community programs within southeastern NC. 

Dr. Michelle Jones has practiced Family Medicine in the Wilmington, NC area for over 26 years. She is a Past President of the North Carolina Academy of Family Physicians and has served as Medical Director of Community Care of the Lower Cape Fear for the last 5 years.

Key Takeaways

What happened? From pure cost savings, to a reduction in emergency department visits, to improved health outcomes, the HOP pilot had significant positive outcomes.
Who benefited? Those outcomes weren’t limited to direct recipients. Every member served by the HOP pilot touched at least two lives, and most services supported whole households.
What’s next? As CCLCF looks to the future to build a new social care network—one which aims to outlast any single funding source—what lessons can be learned from the HOP pilot?

Want to learn more about CCLCF and the Social Care Network Initiative? Visit their website at carelcf.org. If you're interested in supporting this work, reach out to CCLCF directly at info@carelcf.org.

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Narrator

Welcome to the Atromitos Way podcast, where we candidly discuss the everyday challenges facing health and human service providers, including government agencies, philanthropies, and advocates. Healthcare often focuses on clinical symptoms and medical treatments, while many patients lack essential support for non-medical factors which greatly affect health outcomes. Social care networks aim to connect healthcare providers with community-based organizations to address the social determinants of health, such as housing stability, food security, transportation, and access to medical care. From early 2022 to mid-2025, Community Care of the Lower Cape Fear, or CCLCF, saw firsthand what coordinated care can accomplish and what happens when funding disappears overnight. On today's episode, Michealle Gady speaks with two leaders at CCLCF: Sarah Ridout, Director of Community Programs, and Dr. Michelle Jones, Medical Director, who are driving the efforts to build a robust and sustainable social care network.

Michealle Gady

Welcome to the Atromitos Way podcast. I'm Michealle Gady. If you work in healthcare or human services, you already know the problem. Someone shows up at the emergency room with uncontrolled diabetes, but the real issue is that they can't afford healthy groceries or they lost their housing or they have no reliable way to get to a pharmacy. We treat the symptoms, they go home, and the cycle starts again. The research is clear that social factors, where we live, whether we have stable housing or food on the table, shape our healthcare outcomes as much as and often more than clinical care itself. And yet the systems designed to address medical needs and those designed to address social needs have always operated in separate silos. Different agencies, different funding streams, different data systems, rarely communicating. That's starting to change. Across the country, a new model is emerging called a social care network, an organized system that formally connects healthcare providers with community-based organizations and social service agencies, so that when a patient has a social need, it doesn't fall through the cracks. These networks use screening tools, shared data platforms, and coordinated referral systems to ensure that housing stability, food insecurity, transportation barriers, and other non-medical needs are treated as what they are, which is integral to a person's health and well-being. North Carolina has been at the forefront of this work. The state's healthy opportunities pilots were among the first in the nation to allow Medicaid managed care plans to pay for non-medical services, things like housing support, food assistance, and violence prevention. And one organization in southeastern North Carolina, Community Care of the Lower Cape Fear, or CCLCF, ran one of those pilots for more than three years. They saw firsthand what coordinated care can accomplish and what happens when funding disappears overnight. Now, with a new grant from the new Hanover Community Endowment, they're building something more ambitious. A social care network designed to outlast any single funding source. One that brings together health systems, insurers, employers, and community organizations to treat the whole person across every dimension of their life. Today I'm joined by two leaders driving that effort: Sarah Ridout, Director of Community Programs, and Dr. Michelle Jones, Medical Director, both at Community Care of the Lower Cape View. Together, they bring both the operational and the clinical perspective on what it takes to build a social care network from the ground up and why it matters for every community in this country. Thank you, ladies, both for joining me today. Sarah, if we can, let's start with you telling us about yourself and the work that you do at CCLCF.

Sarah Ridout

Sure. So I recently transitioned into the role of Director of Community Programs. Previously, my main focus was leading the North Carolina Department of Health and Human Services Healthy Opportunities pilot in our Six County region, which is the lower Cape Fear region in North Carolina. And we were collaborating with many key stakeholders as we tested non-medical interventions in health care. And now what we're doing is taking what we've learned and the expertise of CCLCF over the past 20 years to apply it to a regional social care network approach, as well as some other collaborative efforts we have in CCLCF and potentially even as the Rural Health Transformation Program rolls out as an NC Roots hub applicant. Dr.

Michealle Gady

Jones, same question to you.

Dr Michelle Jones

Thank you, Michealle. My postgraduate medical career began in Wilmington with Wilmington Health Associates. As a family physician, I attended newborns and patients of all ages at New Hanover Regional Hospital at that time and in my outpatient clinic. I have transitioned to all outpatient medicine that still see all ages. Five years ago, I began work at community care of the Lower Cape Fear as associate medical director to Dr. Henry Hawthorne and then became medical director. My work with CCLCF is to serve as a clinical resource to care managers, pharmacy, and other staff as we support patients and providers. CCLCF has many innovative programs, and my role is one of advisor, advocate, networking agent, educator, and just keeping up with their work.

Michealle Gady

You know, family physician is one of my favorite specialties in in medicine. You know, the whole treat from birth to death is so incredibly important, particularly as we talk about, you know, the things that we're going to talk about now. I always pick a family physician as my PCP.

Dr Michelle Jones

Everyone deserves a family physician.

Michealle Gady

Yeah. I even had my son when he was born. His pediatrician was actually a family physician. Um, all right. So, Sarah, let's talk about the big picture. What is your definition of a social care network in New Hanover County?

Sarah Ridout

So, a social care network actually can mean different things to different people. So, it really does not necessarily need to focus on health outcomes. However, how we're working in and how we're approaching it is really the objective of what we're trying to achieve. So, really, this includes looking outside of the four walls of a health system and into people's lives. It's said, and you've heard it in a couple of different places, we talk about it all the time in healthy opportunities, is that up to 80% of a person's health is determined by their social and environmental factors. So that means kind of for me, my take on social care network is bringing together community-based organizations. You'll hear me flip-flop. Sometimes I say human service organizations, but that's really to bring those groups together to address non-medical drivers that impact a person's health. Some of our listeners may not know what a non-medical driver of health is. That is really a kind of the conditions in the places where people live, work, learn, and play that affect a wide range of their health risks and outcomes. So a social care network delivers those interventions and education to address food instability, housing insecurity. It could be non-medical transportation, workforce stabilization, it could be insurance navigation, interpersonal safety, and toxic stress support are just some of the ways that you can kind of address those things. And then for us, this is really going to be paired with a clinical intervention to improve an individual's long-term health outcomes and self-sustainability. That's one thing that we're really working to do. In addition to obviously continuing to work on those health-related costs, addressing pain points for systems of care and reducing the strain on the systems in place. So, for example, our emergency departments and our hospital systems.

Michealle Gady

So, Dr. Jones, let me ask you as a treating physician in New Hanover County, why does the county need a social care network?

Dr Michelle Jones

I think New Hanover County, like all North Carolina counties, need a social care network. All the counties have residents who are lacking in basic needs, such as the access to healthy food, access to safe walking spaces, transportation to a health care provider. It's a common thread through all the counties in North Carolina. And these factors influence the ability of one to be able to control their diseases, such as diabetes or heart failure. And when these diabetes aren't controlled, when patients don't have access to come to my office or access to healthy food, it leads to more frequent emergency department visits or hospitalizations. With an increase in the population, especially in New Hanover County and the surrounding counties and all of North Carolina, the hospitals and emergency departments are struggling. And we need a way to address this problem with upstream prevention.

Michealle Gady

Sarah, what are your thoughts on that?

Sarah Ridout

Yeah, I absolutely agree with Dr. Jones. I really do think all counties in North Carolina, but also across the nation, could benefit from social care networks. We're really grateful that the new Hanover Community Endowment allowed us to plan one in New Hanover County. But the real goal is to create something that is replicable in other counties. We really do have a great opportunity to work with some of the same key stakeholders we did in healthy opportunities, but even expand on that, like the hospital systems, but again, the health plans for New Hanover County citizens, our local government, and even local businesses and community partners to really dig in and invest on social care integration and health. And I really do think, you know, even if you aren't a direct recipient of a social intervention in one of these networks, you can still benefit as a community member.

Michealle Gady

Absolutely. So, Sarah, you mentioned and I talked about it in kind of our introduction here, the healthy opportunities pilot. Can you talk or explain briefly what that is? Sure.

Sarah Ridout

Yeah, so Healthy Opportunities Pilot, it's a program, and I think, Michelle, you mentioned it a little bit in the introduction. It was really one of the nation's first comprehensive programs to test and evaluate the impact of providing select evidence-based non-medical interventions. And a lot of that was related around food, housing, transportation, and interpersonal safety and toxic stress to a group of Medicaid managed care enrollees. So CMS or Center of Medicaid Medicare Services, they had authorized both the state and federal funds to test the interventions really to see if they would, in fact, improve health outcomes and reduce health care costs.

Michealle Gady

And so, Dr. Jones, as a treating physician within the community, can you paint a picture of what the Healthy Opportunities program accomplished?

Dr Michelle Jones

Well, to speak more globally and not just my practice, I wanted to bring out that the HOP pilot saved six emergency department visits per 1,000 members per month. If we think about the expansion of Medicaid in North Carolina, that's a tremendous number of decreased emergency room visits. And like Sarah said, it doesn't just affect the folks in the HOP program, it affects the folks in the community because they don't have to wait as long in the emergency room if we're not if we have six less folks there. There were two hospitalizations saved per 1,000 members per month and $85 per month per participant. That's a significant amount of money. This program also helped kids with type 1 diabetes learn to eat healthier meals. And it prevented hospital admissions for those kids. It helped install mold-free flooring and homes and prevented asthma exacerbations and emergency room visits for those folks. And it generated hundreds of local jobs through the community-based organizations that Sarah just spoke about and millions of dollars back to these same communities. So it's keeping those dollars there in the community where we all live and play and work.

Michealle Gady

Sarah, when Hopp was paused in June of 2025, what happened?

Sarah Ridout

Yeah. So presently, the you know, proposed House and Senate budgets put forward by North Carolina General Assembly does not include funding for healthy opportunities, pilot operations, or statewide scaling. I will say the pause felt very abrupt. It um gave us little time to transition enrollees to those external resources. And there were even some interventions that were very challenging to complete. So, you know, we had to wrap wrap up putting ramps on homes, or even some members may have not been able to complete their series of, you know, mold or pest infestation treatments. After the pause, one of our organizations reported that during one of their single mobile food market pop-ups, and this was based in a rural area, a very rural area, where, again, transportation can be a really big issue. They reported that 116 families showed up to that mobile food pop-up. And all the food was, they ran out of food within 40 minutes. So typically before hop, they averaged about 50 families per event. And then we had 116 families show up. So, and half of those, about half of those families were former hop or healthy opportunities pilot members. So essentially that need did not disappear. Um, and all of those folks are now leaning on the same limited resources. And, you know, again, some of those resources may not necessarily be tied to better health. Another thing that we saw during the PAUS was care managers. So care managers working with those members, with the members' health plans, really seeing kind of the fallout from the pause. One thing that we did locally was we went ahead and put together a survey within weeks of the PAUS and really trying to see what was happening on the ground with care management. We discovered around 79% of those care managers that responded could not meet members' goals. Um, and due to the lack of the resources, over half of them spent more time on crisis calls than proactive care. And that included higher emergency room visits, hospitalizations, and even increased homelessness. And a lot of those care managers also saw members disengage from their care and from their health plans.

Michealle Gady

Yeah. Dr. Jones, what did it feel like for your, you know, kind of your patients or individual patients that you've, you know, spoken with colleagues about and the community as a whole. What did you see from that perspective when hop paused?

Dr Michelle Jones

Well, we kind of enjoyed the hop services when they were going for those three years. And when it stopped, it felt like somebody couldn't get a ramp when they needed a ramp. We, you know, we were attuned to these needs, and then suddenly we were not able to meet these needs. It felt like a broken hip. Someone had fallen, and you couldn't help but think, would they have fallen had they had the rails in their home? It felt like people skipping meals or not eating meals. It felt like the waiting room in the emergency department took a few hours longer. One story from a hop and roly stated, and I'll quote, without hop, I don't get to eat two times a day. I must decide when to eat. Being a diabetic makes it harder on me. And I don't have the money to buy food because of my pills. So, Dr.

Michealle Gady

Jones, can you bring that story to life that you're talking about? You know, so many people need these services. So every member you serve um touches two lives, essentially. So, as most services support whole households, can you are there any particular stories you can think about to help us understand that?

Dr Michelle Jones

Sure. If you provide a set of interventions that, for example, provide long-term housing stability, then the whole family benefits. And sometimes we have folks who live in multi-generational households. If a mother was eligible for hop, the children would also benefit from not being homeless. If you provide a healthy food box and food and nutrition access case management to a father who is diabetic, not only are you helping him to better manage his diabetes and lower his A1C, but you are potentially helping keep him out of the emergency department. If he goes to the emergency department, he can't go to work that day. If he has children, he has to look for child care or the children go with him to the emergency department. And we know that's a risk of them getting sick. He will also use healthy food items in a food box to cook his meals and he will share with his children. So it's really not just the individual, but these as really affecting the folks' families.

Michealle Gady

So, Sarah, the the healthy opportunities program was uh, you know, kind of the first in the nation, and anything first comes with challenges and frustrations. Can you talk about what some of those were that you experienced during that process?

Sarah Ridout

Yeah. I mean, you know, we have to remember that for a healthy opportunities pilot, there were a lot of stakeholders that came together that had never worked together before. Um, we had a lot of community-based organizations that had never been a Medicaid vendor before. So this was very, very new, working collaboratively together and really in a very, very new space. I will say one of the biggest things that we saw, initial frustrations, was around invoicing and reconciliation processes between the health plans and the community-based organizations. Again, we're seeing six health plans participated in healthy opportunities within our region. It was a little bit different across the state. But that meant that those community-based organizations had to do their invoicing and reconciling, set up the portals and all of the work that goes around that with SIF, six different health plans. So that really did evolve. I will say that, you know, again, that's part of a pilot where you look at that, you begin reducing those barriers, figuring out how to evolve some of those challenges. And that did occur, but we did still see some of that. And then a little bit too, you know, I think with the eligibility criteria, it was restricted to your high-risk Medicaid managed care members with one or more chronic conditions, plus one of those social health-related social needs, right? So that meant somebody with Medicare or traditional Medicaid or no insurance or even commercial insurance, but still was high risk, could not participate in the pilot. But again, it was a pilot, right? We that was very intentional. We wanted to test to see, you know, how what would work. We were within a limited time frame. And so it was intentional to have some of those restrictions. So then we could see, you know, does this work? What does the data show? And then we could expand it to other populations.

Michealle Gady

And so kind of building on those lessons learned and that experience, can you tell us, Sarah, about the new social care network initiative with CCLCF?

Sarah Ridout

Sure. So again, we saw very positive outcomes. Dr. Jones alluded to some of those in healthy opportunities pilots that included a person's health emergency department utilization, hospital admissions. And then when HOP did pause, it really did create a gap in resources and with our care managers. And North Carolina really invested a lot into the infrastructure and data collection to show this proof of concept. So, really, that was the catalyst for a regional approach, not only to leverage the infrastructure we already had in place, but to really use the evaluation findings and lessons learned. So, what we did was we kind of thought about, you know, let's sit down, you know, certainly in parallel with healthy opportunities, seeing what the North Carolina General Assembly does. And at the same time, can we create a regional social care network as really like a collective investment in both community and economic health? So we approached the New Hanover Community Endowment with this, and they were very generous in giving us a planning grant where we could actually work with 17 of the nonprofit organizations that participated in healthy opportunities, but also have a footprint in New Hanover County. So again, going back that to that collective impact and effort as we're really planning and building this out. We're taking what we've learned from Healthy Opportunities pilots, we're looking at other states who have. Been innovative in this work that have their own, you know, maybe like an 1115 waiver and doing social care network work. Um, we're talking to other key stakeholders that participated in healthy opportunities to really build out a regional hub focused on health and social care integration. And again, we want to stick to, because it is the mission and vision of community care of the lower Cape Vier, you know, how do we improve health outcomes? How do we really reduce health care costs and reduce the strain on resources in New Hanover County? And again, we want this to be replicable, right? Um, it's we're very grateful to be doing this work in New Hanover, but we want to be able to do this in our rural counties and even statewide.

Michealle Gady

So as you're building the new social care network, it's not just a recreation of HOP. There are some differences. And so from each of your perspectives, can you identify what some of those are? Let's start with Dr. Jones and then Sarah.

Dr Michelle Jones

I think the most exciting difference in this program is that it will be open to everyone, not just the single payer. When we were doing hop and it was just Medicaid, and we would see a Medicare patient or someone with commercial insurance, it was heart-wrenching. I mean, we always said we needed hop for Medicare, we needed hop for commercial insurance, we needed hop for those that were uninsured. Everybody needed it. So that's going to be what really one of the exciting things is that we can have these services for anyone in the community, anyone in New Hanover County, thanks to the endowment. And the other thing is that care navigators can screen for other needs. So this was part of the Healthy Opportunities pilot. And one of the beautiful parts of that program was it was an open door policy. If someone came in with a food need, they would also be screened for other needs. And some of these needs may not be obvious to caregivers like me, the physicians, and may not even be evident to the patients themselves. If the patient's asthmatic and they're living at home with a carpet that's covered in dog hair or whatever, these carpets need to be removed. And the patients may not even realize that that need is there. So those are two of the most exciting things to me about the new social care network.

Sarah Ridout

Sarah, I would agree. I think everything that Dr. Jones said, plus, we have a really interesting opportunity to look at some of the services and change them around just a little bit. You know, obviously we want to remain evidence-based. We want to have services or interventions that are always tied back to health outcomes and health care costs. But can we approach it in a little bit of a different way? And healthy opportunities, you know, somebody may have received a food box, and, you know, we had other interventions that could complement, but it wasn't required. And so we have opportunity to maybe bundle, you know, some of these interventions a little differently. So, you know, that way, if somebody, you know, or somebody that comes in and wants to plug into the network for a particular population, or, you know, maybe there's a philanthropic group that wants to join the network and work around housing instability, that we could have a bundle of interventions around housing instability. Or as Dr. Jones mentioned, asthma or even diabetes. Can you bundle some of these non-medical interventions around a particular chronic condition? And then with that, we add in education, right? It's the education component. It is connecting back to your primary care. It is creating a behavioral shift and long-term self-sustainability. And then you can kind of layer in other types of education, you know, just anything around, for example, is it time for a mammogram, right? That may not be part of a particular service intervention bundle or non-medical intervention, but you can layer on some of those other things that really help support somebody's overall health. And then I think another difference in, and I mentioned this earlier with our organizations in invoicing and reconciliation. One thing we learned was that the admin burden, administrative burden associated with this pilot, again, could be a little challenging at times. So one takeaway was is there something we could do where there's a centralized approach to some of these processes, right? Invoicing and reconciliation specifically. Again, managing with six health plans is a lot for any organization, but can we, as the network lead, really take that responsibility and risk on so those organizations can really concentrate in what they do best, right? Can they just go ahead and focus on delivering that high-quality intervention like mold remediation or a medically tailored meal?

Michealle Gady

And so, Sarah, you know, you mentioned the importance of a primary care provider. Dr. Jones, can you talk about how you see the role of a primary care provider working within this kind of integrated social care network?

Dr Michelle Jones

Yes. Well, first we want to meet the patient's immediate needs. So if they have immediate need for food, we really want to make sure that they get what they need there. But then also connecting the patient to a primary care physician or provider will allow them to have a medical home. And that's a trusted partner in their health and an advocate in the health care system. Most health needs can be met and chronic disease is managed in a primary care setting. An annual wellness visit for Medicare and routine health visits for commercial insurance and Medicaid are important to discuss health screenings such as mammograms, colonoscopies, to detect disease when it's early and best treated, and then vaccinations to prevent disease. And why is this important? Because research shows that people who have a primary care provider live longer and healthier lives. And this saves money in the health system. Nearly every country with better health statistics than the U.S. invests more dollars in primary care and preventative medicine than we do here in the U.S.

Michealle Gady

And uh, Dr. Jones, continuing to build on what Sarah said, you know, she talked about the bundled service approach. What might that mean in practice from a physician's perspective?

Dr Michelle Jones

So we're familiar with bundled services like phone, internet, television. We hear that term all the time. And as we consider the bundling of services in medicine, we could think about it this way. A nutritional support bundle could include a number of things. One, it could include at-home meal programs such as meals on wheels. It could include food assistance in navigating SNAP benefits, healthy food boxes for diabetics, education to support behavioral shifts and create self-sustainability. So that all could be one food bundle for someone that was interested in food bundles or food for a community. Another could be housing stability and environmental safety, and that could include repairs or modifications of tubs and showers to prevent falls, connecting seniors to stable, accessible housing, removing molds or carpets to decrease disease, and then housing navigation and utilities assistance paired with education around budgeting and finances, being a good tenant, a workforce development if needed. So that could be a housing stability and environmental safety bundle.

Michealle Gady

And so kind of thinking about earlier, Dr. Jones, you mentioned that HOP was limited in terms of eligibility. So as CLCF envisions the new social care network, eligibility is deliberately brought, sort of one of those lessons learned. There's no income limits, no age restrictions. If you have a documented social need, you can be eligible. Why is that important?

Dr Michelle Jones

Well, the network itself has wide guidelines to not intentionally deny access. Entities that use the social care network may have stricter guardrails around eligibility. For example, if a health plan plugs into the network, they may provide use of services specifically to their plan's members. Another entity that plugs in may focus on a specific census track, a specific demographic, a chronic disease condition, or health-related social needs such as housing stability. Social needs come in a variety of ways and from many different individuals in a community. And we don't know who's going to be able to be part of this social care network. I mean, someone may be interested in just housing needs and want to plug into that part of that bundle.

Michealle Gady

So, Sarah, earlier in the podcast, you mentioned that even if, you know, a person isn't a direct recipient of social interventions, you benefit. Can you explain a little bit more about that?

Sarah Ridout

Yeah, absolutely. So again, we saw, you know, we we've talked about this a little bit, but the interim evaluation reports where you can see for healthy opportunities pilot, Mizal Public Facing, really did show the health cost savings as well as the uh decrease in emergency department utilization and hospital admissions. So if you are somebody who is not a direct recipient, however, you live in the community, that could mean a loosening up of resource. So if your loved one or you had a true health emergency, that could mean that there is a resource more readily available. That could be the emergency room, that could be a bed in the hospital, it could be getting an appointment with a specialist or even access to a first responder. And then a second thing is your experience kind of in the community. We happen to live in a very touristy area in Wilmington. We're near the beach, we're near the river, and we have a very high kind of service need in our region. And right now, I kind of found that approximately 61% to 64% of non-disabled working-age adults on Medicaid are employed, with a significant portion of those working in the service sector jobs. So in your accommodations, in your food services, in your retail. So with us living in a very kind of touristy area, we have a lot of people coming in, that's gonna affect how those tourists, you know, experience the community. That is gonna factor into how you, as somebody living in New Hanover, will also experience that in your community, right? If you're going to a restaurant or if you're, you know, doing any of those things. And then I think the biggest thing too is one thing that we saw in healthy opportunities is there was this secondary effect that was more of an economic impact. Um, we recently conducted an economic impact analysis for healthy opportunities pilot in our six county region. And between January 2022 and August of 2025, the program invested around $103 million into the regional economy. And that investment really supported over 1,400 new full-time equivalent jobs, about $58 million in labor income. And then there was an additional $59.6 million in ripple effects through supplier in household spending. So really that investment and then the ripple investment supported local farming and agriculture, small businesses, the housing industry, again, a lot of our restaurants and medical providers, but even things like auto repair. So that economic impact was absolutely huge. And so, again, as we look to putting in a social care network in our region, we think that we will see some of those same economic impacts as we did with healthy opportunities.

Michealle Gady

So a goal is to continue that ongoing economic development within the community.

Sarah Ridout

Absolutely. Because again, if you invest locally, if health plans, if hospital systems, if local businesses, if local government invests in this social care network, then that that money is going to go right back into your community, right? You're going to be because the organizations we work with work very closely with local farmers. They work very closely with small businesses and subcontractors to do the work. And again, then you're turning back into the community where, you know, then you're going back to those stores. You're you're putting money back into your community.

Michealle Gady

Yeah. From a clinical standpoint, Dr. Jones, you know, one of the important things that we've talked about is kind of this idea of centralization, having the social care network lead is kind of the central point for this. How does that, what does that mean for patient care? How does that support you as a physician?

Dr Michelle Jones

Well, just an example of centralization from my practice, and then I'll relate it a little bit to the social care network. An example of centralization of care is when my patient or a patient calls my office for an appointment, they will get a centralized scheduler who has access to my schedule and also my partner's schedules. They can be offered an appointment with me, but if I'm not available, rather than having the patient call the other provider's offices, the scheduler can efficiently accommodate the patient. And it only takes one call for the patient. And really, this is a win-win for the office and the patient, and it saves time and money. The same thing is true for the social care network. There really is just one call. And then the services can be provided for that patient, but then also screened for other services all within the same agency. They don't have to call the food bank and then the transportation bank and the housing bank. It's all centralized. So it just makes sense and it's efficient. And it really allows a patient to be able to get what they need without having to go to different areas. And the most important thing about this is that many times providers don't know these services. That's not something that we're taught. So this is a specialty or specialist group of care navigators, care managers who know the resources in the community, and it just takes one call to one of them to be able to provide resources for the patient.

Michealle Gady

So, Sarah, under CCLCF's social care network concept, you're centralizing many of these functions across multiple organizations like contracting and billing and intake, quality improvement. These are things you learned were important during HOP. So building on that HOB experience, why centralized versus allowing each organization to handle its own?

Sarah Ridout

Yeah. So again, one thing we really learned with Healthy Opportunities is we have a lot of amazing organizations who do incredible work in our region. But sometimes that work and the efforts are siloed a little bit. So this is was again going back to what Dr. Jones said, you know, a real opportunity to kind of break down some of those silos, but also begin to reduce some of the administrative burden that occurs just when you work with multiple health plans, again, multiple contracts. That is that is a lot to contend with if you are a human service organization that is also doing other things, right? So it is not just that they're doing this one thing, they have multiple grants, they may be doing fundraising in other spaces. There's a lot of work that these organizations do in our region. And so if we're able to handle the invoicing and reconciliation, for example, that really is going to reduce the administrative burden for that organization. Um, and then their overhead costs go down too, right? Because then they don't have to have a subject matter expert in that particular space where then they can really kind of put that money back into their materials and then other places. And we've even had organizations that are able to then take what they've gotten reimbursed and actually use it for other programs that may not have the funding, but are so important to the community, right? Very, very valuable and highly impactful to the community. Another thing, too, is that we can centralize, again, to reduce that burden, but also it is around the quality improvement and compliance piece of it. If you have a benchmark, that is, this is the benchmark for quality improvement initiatives and compliance in our network, right? Then we manage that for those organizations. And we are then able to always make sure that the end user, the eligible member that comes in or the investor has an experience that is high quality. It is vetted, right? And if there is an issue, then we handle that and we work with, you know, the organization for to make sure that we're back into that quality space and within compliance. So again, I think part of it too is removing some of that and allowing the network to really help support those quality improvement initiatives across the organizations. But that doesn't mean that every organization is cookie, is, you know, cookie cutter. It still allows for some uniqueness in their service intervention approach.

Michealle Gady

So, Sarah, you talked earlier about the loss of funding in the state budget, which I think taught CCLCF an important lesson in terms of relying on a single source of funding and how risky that can be. So, how do you plan to build sustainability different for the social care network going forward?

Sarah Ridout

Yeah, I absolutely agree. I mean, you know, again, when healthy opportunity paused, it was, you know, it was very, very challenging. And that's the way it was set up, right? It was set up as that kind of single funding source for the networks and then all the key stakeholders. But that was a lesson learned. And I do think we see it all the time anyway on a smaller scale, right? So if you're a nonprofit, you may have different grants and awards. And once they end, the program ends, right? Or you're scrambling to find the next thing to keep that program going. So it is very important for long-term term sustainability for us to diversify and really have multiple entities to invest in this network. So, for example, having health plans invest in the network, your hospital systems. It could be a philanthropic group or research group. It could be local government, it could even be a local business. So that also means, though, that on our end, it has to be worth it to the investor, right? So, what are the desired health outcomes? How are we factoring in the impact of things beyond the desired health outcomes, such as cost reduction, resource provision, local economic investment? So, you know, we really want multiple investors to really come into this, but we also recognize and acknowledge that we need to understand what each entity wants to achieve and how we can collectively work towards those goals.

Michealle Gady

So, Sarah you talked about having multiple investors in the social care network, whether it's healthpayers or employers or local government, et cetera. I think one of the important distinctions between the social care network and the hop pilot is that hop was focused very specifically on Medicaid. And so it kind of leads to this question of wouldn't it only just be relevant to Medicaid? And so, do you see a pathway forward where these services through the social care network are relevant beyond folks with low income or limited assets?

Sarah Ridout

This is one thing I've thought about, for example, like with local government or just a local business, right? Where you're there, they may have health insurance premiums, right? Where they're and there could be a couple of chronic conditions for their employees that may be raising the rates. A local government or a local business could come into this network to focus in on those particular chronic conditions, right? Absolutely.

Michealle Gady

And just because you have insurance through your employer and you have diabetes, maybe your premiums are so high because, oh my God, the world today, premiums are so high that maybe you can't afford those really healthy meals that you need to have access to if there isn't some other source of funding. So it doesn't mean that because you're a middle income earner in local government with good insurance, good insurance, that you can still afford to buy the meals that you need to have to manage your diabetes. Okay.

Dr Michelle Jones

Can I try because I think this this is even more basic than that? This is the well-to-do Medicare recipient who has chronic disease and can't drive because they have macular degeneration. They just need transportation to the physician's office. So it can be a really basic need in someone that otherwise has the resources but maybe doesn't. Know how to get in touch with someone that's a reliable someone to transport them that's safe. We don't think about that. We think people with means and Medicare insurance, you know, shouldn't have any issues, but there are real issues out there that are very basic, very simple. And someone that otherwise has resources but just doesn't know where to go. Right.

Michealle Gady

And I think that's key that just because you may have the money to acquire the thing doesn't mean you know how to acquire the thing or who to call or what to do or how to get it.

Dr Michelle Jones

Especially for a senior who, you know, wants to be safe and be safely transported, but doesn't know the safe company to transport them.

Michealle Gady

Dr. Jones, it sounds like the social care network needs to have kind of buy-in from health systems and health payers, but maybe their current business model doesn't align well with this work. How do you think we go about changing that? What needs to change?

Dr Michelle Jones

Well, Hopp did show that there is cost savings in this model. And it seems counterintuitive, but a healthy food box or a bathroom guardrail is a lot less expensive than an emergency department visit or a hospitalization. And we need to continue to replicate this model. And insurance beneficiaries should request these services. While there is tremendous benefit in a health plan providing value-based services to their members, not all plan members are eligible for the value-beded service, and it's typically short-term. A plan or hospital system can do both. Entities that plug in will have one contract with a network lead, ensuring service quality, compliance, and an overarching performance benchmark in a vendor's data privacy and security, data collection, and reporting methods. From an intervention perspective, we know that people in vulnerable spaces rarely have just one social need. If someone has a food insecurity, they may also struggle with utility payments or being able to transport to a food pantry or a grocery store or a doctor's office. A network hub allows community-based organizations to work collaboratively with the participant and their care team, as well as identify additional cross-sectoral interventions as they arise.

Michealle Gady

And so as we kind of are approaching the end of our conversation, when you look at what you're trying to build, um, there are some hard parts to it. And so, Dr. Jones, kind of starting with you, what do you think some of those hard parts are? And then Sarah, I'll ask you the same question.

Dr Michelle Jones

The hardest part from a clinical standpoint is really bringing awareness to that the need even exists. Those needs are not always seen or appreciated even by a health provider. Sometimes when patients don't show up to an office visit, we just consider them a no-show and not really consider the fact that they may not have transportation until the problem becomes an expensive crisis and they end up in the emergency department transported by an ambulance. So it's also breaking down the barrier of, well, we can just do it ourselves. Collective impact takes work, but the results are tenfold. Integrative systems of care begin to work in lockstep, reducing duplicative interventions, funding, and philanthropic siloing and data fragmentation, while communities and local businesses can see increased economic stability and impact.

Michealle Gady

Sarah.

Sarah Ridout

Yeah, I can say there are a lot of intricacies to framing out a social care network. We really learned that as we were walking through Healthy Opportunities Pilot. You know, you really think about putting together a blueprint for the overarching structure, but you've got service intervention or bundle definitions, you have fee schedules, you've got model contracting and the quality improvement processes. There's even, you know, how do you onboard and provide training and technical assistance for the network of human service organizations? Where do you have those shared data and metrics? So there's a lot to contend with when you put together a social care network. But the really good news is we are not starting from scratch. We really did learn a tremendous amount as a network lead, and we continue to evolve. We are working with, like I said, around 17 human service organizations that are helping us build this out. We still rely on the expertise of care management and clinically integrated networks, some of the health plans, and even what we learned from the North Carolina General Assembly, right? What they wanted to see, some of their feedback. And then, of course, there's other states that are piloting this innovative work and doing some of this. So, you know, we're not reinventing the wheel in some of these spaces. We're really taking what we've learned and applying it to this network.

Dr Michelle Jones

One of the things that Sarah alluded to previously was that insurance companies or different PHPs, as they look at their patient panel and their actuarials, may find that there's segments that their diabetes is not controlled, or there's some other issue that they can identify. Those are insureds that can be plugged into a system like this and really drill down on what the issues are and help those patients, but also improve the bottom line of these insurance companies because the patients are getting better care. So that's just an example that I wanted to give of a way that this could really work for a payer or an insurance company.

Michealle Gady

Absolutely. So we are at the end of our time, but I want to give each of you kind of the final concluding remarks. Um, for both of you, any final thoughts on this? Um what do you need from the community to make the social care network work? You know, whatever occurs to mind. Final thoughts.

Dr Michelle Jones

Well, my hope is for increased awareness of a social care network and that it benefits both payers, patients, and communities because where we spend less money on health care, we have more money for roads, more money for schools, more money for parks. It really just makes sense.

Michealle Gady

Absolutely. Sarah, anything you want to add?

Sarah Ridout

Yeah, I think it's just, you know, again, there's the goal is really to have something that is sustainable, right? That it continues to remain deeply rooted and connected in the community where you're consistently seeing an evolution and how it's done, that all parties really lean into making it better and making it work, that you are leveraging data, right? You are pulling together all of these groups that are working collectively, where you're showing the outcomes, you're looking at the data, and that can help change policy, right? And we want to we want this to be in all eyes on New Hanover County. We don't want to hold this closely. We want to share with other counties, with other states. Here's what's working, here's what's not working, you know, we want to hear from other states too. Like this is, you know, a bundle that we're seeing positive outcomes in on. And so we can adopt that as well. So we want this to be a shared experience where it's not just us, we're not gatekeeping, because the goal is to really make this work and really truly make healthier communities and integrate that health and social care.

Michealle Gady

Thank you both very much. I appreciate you joining me today to talk about the social care network. I really do think it's a tremendously, you know, we use innovation and transformation in healthcare all the time, but I think this actually is that. Um, and so to our listeners, if you want to learn more about Community Care for Lower Cape Fear and the social care network initiative, visit their website at carelcf.org. If you're a health system, if you're a funder or policymaker interested in supporting this work, reach out to CCLCF directly at infocarelcf.org. Thank you, everybody.

Narrator

Thank you for listening to this episode of the Atromitos Way. This podcast is a production of Atromitos, a woman-owned boutique consulting firm that creates a better way for our health and human services provider clients to achieve their goals by strengthening internal operations, enhancing financial stability, and evaluating public policies. Please follow the show and leave a review. You can find previous episodes and more content on our website, Atromitos Consulting dot com slash Atromitos Dash Way. That's A-T-R-O-M-I-T-O-S. We'll see you next time.