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Case Management and Outreach

Case Management and Outreach



Care Coordination for Children (CC4C) is an at-risk population management program that serves children from birth to 5 years of age who meet certain risk criteria.  The main goals of the program are to improve health outcomes and reduce costs for enrolled children.  Each child served by CC4C is linked to a specific Medical Home and CC4C Care Manager.  Services provided by CC4C care managers are tailored to patient needs.  The CC4C Program is administered as a partnership between Community Care of North Carolina (CCNC), the NC Division of Public Health (DPH) and the NC Division of Medical Assistance (DMA).

Referrals originate from the medical homes, hospitals, community organizations, CCNC care management staff or families and can be submitted on paper or taken by phone.

For more information go to:



Who is Eligible?

  • Children from birth to age 3 who are at risk for developmental delay or disability, a long term illness and/or social, emotional disorders.
  • Children from birth to age 5 who have been diagnosed wtih developmental delay or disability, long term illness and/or social, emotional disorder.
  • All children identified has having priority risk factors will be assessed by a CC4C care manager.

Program contact:


Bonnie Boone, Social Worker  252-534-5841 (ext) 573






Health Check and NC Health Choice for Children programs provide free or low cost health insurance to children and teens who qualify.  Health Check (Medicaid) is North Carolina's Medicaid program for children.  NC health Choice is health insurance for children of working families who do not qualify for health Check (Medicaid) but who may not be able to afford private insurance.

Program contact:

Latonia Leary,  Health Check Coordinator  252-534-5841  (ext) 602





COMMUNITY CARE PLAN OF EASTERN CAROLINA (CCPEC) is one of the 15 regional networks within the state's healthcare quality improvement partnership called Community Care of North Carolina.  CCPEC consists of primary care physicians and community organizations such as public health, social services and hospitals, which have voluntarily come together in controlling costs for Medicaid's Carolina Access population.  CCPEC has Care Managers available to help with the following:

  • By coordinating care, providing education about diseases and medication adherence and by helping the client set realistic goals for better health.
  • By ensuring post hospital follow-up care with the client's healthcare provider to maintain medical standards of care.
  • By introducing clients to resources in their area as well as teaching them how to access and use these resources.
  • By receiving referrals from healthcare providers, other healthcare organizations, schools, Medicaid database and self referrals.

Pregnancy Care Management PCM

Pregnancy Care Management (PCM) provides comprehensive, coordinated maternity care to pregnant Medicaid patients collaborating with public health to ensure high-risk patients receive case management and improve birth outcomes in North Carolina. PCM's objective is to improve stewardship of limited perinatal health resources and, through risk assessment screenings, reduce preterm birth rates as well as low birth weight rates.

Pregnancy Care Management is a statewide program in North Carolina promoting healthy mothers and healthy babies.  The Northampton County Pregnancy Care Management Program is designed to improve birth outcomes by providing care management services for high risk women during pregnancy and for two months after delivery.  Our Pregnancy Care Manager is a highly-skilled social worker who helps the mother get WIC, Medicaid, food stamps, support and counseling, and parenting education. 

Program contact:

Carol Lee, Social Worker   252-534-5841  (ext) 661

Home Delivered Meals

The Home Delivered Meals Program or "Meals on Wheels" is funded primarily through donations and Home Community Care Block grant funds awarded by Upper Coastal Plain Council of Governments.  The main goal of this program is to provide a minimum of 1/3 of the daily recommended dietary allowances established by the Food and Nutrition Board of the National Academy of Science.

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