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Programs & Initiatives

Programs & Initiatives

Programs & Initiatives

To achieve our objective of improving health outcomes and reduce care costs for Medicaid enrollees, we have developed a variety of evidence-based programs and initiatives to outreach to the population.

ABCD/Early Intervention Program

  • Using proper developmental screening tools, we work to EARLY identify delays and disabilities which lead to therapies and services to help children be more successful when they reach school age. We are setting the stage for SUCCESS!

Behavioral Health Integration

  • CHP is committed to applying an integrated care approach to all programs in our network. Our network psychiatrist, behavioral health program coordinator, and our integrated care team provide education and support to patients, nurse care managers, and primary care practices to both identify and manage medical and psychiatric comorbidities. Our network psychiatrist is available to primary care practices for telephonic consultation and practice visits.

Care Coordination for Children (CC4C)

  • Targeting high-risk, high-cost children from birth to age five for care management.

Care Management

  • Ensure the full circle continuity of care that occurs between providers, hospital, and home.

Care Transitions Project

  • The goals of the Care Transitions are to improve transitions of patients from the inpatient hospital setting to other care settings. With comprehensive transitional care from a clinical aspect as well as a social aspect, you can expect to see improved quality of life as well as lower mortality rates. The patient benefits from an improved quality of care, a reduction in hospital readmissions, and often times measurable savings to the Medicaid and Medicare programs.

Chronic Pain Initiative

  • The objective of this initiative is to support health care providers and community stakeholders around efforts to increase patient safety, improve pain management, and reduce the risk of overdose and drug dependency related to opioids and other pain medications.

Fostering Health NC

  • A project that focuses on strengthening medical homes for children placed into foster care to ensure they are being seen early and more often.

Health Check Coordination

  • To ensure children have uninterrupted access to a medical home and to help families fully utilize their medical home for sick visits and preventive health care services such as well child check-ups, immunizations, and dental care.

Medicaid Medical Necessity Review Program (MNR)

  • Care Management Decision Support assists physicians/medical homes in determining the amount, duration, and scope of a Medicaid service (PCS or In-Home Care Program) as well as Durable Medical Equipment to meet the clinical or health needs of the patient and to support medical need determination.

Palliative Care

  • Building awareness around end of life care needs and advance planning.


  • As one of the 14 networks under CCNC, Community Health Partners has established a Pharmacy Quality Program. Under this program, our Network Pharmacy Program Manager (PharmD) and Clinical Pharmacist (PharmD) provide education to primary care providers and pharmacists about Medicaid policy, assist with patient pharmacy management through medication review/ medication reconciliation, assist providers in choosing cost-effective therapy, assist patients with medication coverage at the pharmacy, and serve as a resource to nurse care managers, primary care providers, PCP office staff, and community pharmacists.

Pregnancy Medical Home

  • Serves mothers-to-be who are eligible for Medicaid and are having high-risk pregnancies.

Quality Improvement

  • Assisting network practices with Quality Improvement Projects and initiatives to improve patient outcomes.