Community Health Worker Program

Bridging Community and Systems for Better Health and Well-Being

Community Health Worker Integration into Primary Care Advanced Medical Homes

Community Health Worker (CHW) services and programs are crucial in helping Advanced Medical Homes improve chronic disease self-management and health outcomes, enhance the patient experience, reduce emergency room utilization and hospital readmissions, as well as impact health equity and overall healthcare costs.

The NC AHEC Community Health Worker (CHW) Program supports the development of a qualified and sustainable CHW workforce well equipped to advance health equity. While NC AHEC serves as an anchor partner in the NC CHW Initiative, the NC DHHS Office of Rural Health serves as the lead agency. For more information about our work, contact Gwen Arnold at

NC AHEC Practice Support is available in partnership with NC DHHS Division of Health Benefits. Practice Support coaches are able to support primary care practices interested in adding CHWs to their teams or optimizing existing CHW programs. This service is available at no charge to your practice. Visit the NC AHEC’s Practice Support webpage for more information, or contact us via email at to seek assistance.

CHW Workforce Training & Support


This training is offered through the NC Community College System and is required for CHW Certification in North Carolina. Learn more by visiting

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These online modules focus on the professional development and training of CHWs:
COVID-19 CHW Training for NC AHEC CHW Initiative:
This self-paced online course helps connect the health workforce to COVID-19 related community-based resources for patients and their families. Available in English and Spanish.

CHW Integration into Advanced Medical Homes:
These self-paced online modules will prepare CHWs and practices for integration into primary care as part of Medicaid Managed Care. Modules will be released in English and Spanish on a rolling basis beginning December 2021. This service is also supplemented with Practice Support coaches with expertise in CHW optimization within your practice or Advanced Medical Home.

These modules are being developed with support from the NC DHHS Division of Health Benefits and will be made available free of charge.

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This ECHO-based series brings CHWs from across the state together to support shared learning. The series is co-hosted by CHWs with topics selected through input from participants. Sessions are held monthly every third Thursday at noon. Live English-Spanish interpretation is provided.

Resources for Effective CHW Integration

This tool is an evidence-informed comprehensive resource that includes a gap analysis, implementation resources, and a project management plan for integrating new or optimizing existing CHW programs in Advanced Medical Home settings. NC AHEC Practice Support coaches are able to assist you with the use of this tool as part of your CHW optimization efforts. For more information, please contact

The Toolkit was developed with support from the NC DHHS Division of Health Benefits, NC AHEC, and the Rita and Alex Hillman Foundation.

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Two 8-session ECHO series will be offered in 2022 to Advanced Medical Homes (AMH) interested in preparing for, optimizing, and/or implementing CHW services and programs. More information will be available January 2022. This series is offered in conjunction with 1:1 support from an NC AHEC Practice Support coach as needed by the practice or AMH.

These ECHO series will be offered with support from the NC DHHS Division of Health Benefits and will be made available free of charge.

Tailored Care Management

A Coordinated Approach to Behavioral Health

What is NC AHEC’s role with Tailored Care Management (TCM)?

North Carolina Department of Health and Human Services, Division of Health Benefits (DHB) has partnered with NC AHEC to provide statewide practice support, education, and technical assistance to Advanced Medical Home Plus (AMH+) and Care Management Agency (CMA) organizations who pass the TCM desk review component of the service certification process. The purpose of AHEC’s technical assistance is to enable AMH+/CMA candidate organizations to successfully complete organizational site reviews and achieve certification. AHEC’s program is also designed to equip TCM candidates with the tools and knowledge to effectively provide care management services to North Carolina’s Tailored Plan beneficiaries.

Through Tailored Care Management (TCM), scheduled to launch July 1, 2022, Behavioral Health (BH) – I/DD Tailored Plan beneficiaries will have a single designated care manager supported by a multidisciplinary care team to provide whole-person care management that holistically addresses their needs. This includes physical health, behavioral health, intellectual and developmental disabilities (I/DD), traumatic brain injuries (TBI), pharmacy, long-term services and supports (LTSS), as well as unmet health-related resource needs. 

The success of Tailored Care Management will depend upon BH/IDD Tailored Plans, AMH+ practices, CMAs, pharmacies, physical health, behavioral health, and I/DD providers working together to provide a coordinated approach to beneficiary care.

For more Tailored Care Management service and certification information and resources and to download the application to become an AMH+ or CMA provider, please visit the DHHS Division of Health Benefits Tailored Care Management webpage. And, be sure to check out a new DHHS webinar series, Tailored Care Management 101, designed to help develop a shared understanding of the model across the North Carolina provider community (including advanced medical homes and behavioral health, I/DD, and TBI providers). The webinar series will run from October through mid-December, on Fridays from noon to 1 p.m. Please note this webinar series is offered at no cost and is voluntary.


Tailored Care Management, Learning Collaborative Sessions

AMH+ and CMA organizations who have completed their Tailored Care Management (TCM) application and passed their TCM certification desk review, are eligible and required to participate in the TCM Learning Collaborative sessions provided by NC AHEC at no cost. The sessions are designed to provide content experts and peer-to-peer learning opportunities to AMH+ and CMA organizations as they prepare for TCM implementation and site reviews by the North Carolina Department of Health and Human Services. Sessions will continue every first and third Wednesday of the month from 12:30–1:30 PM.

September 1, 2021 | Gap Analysis Tool & Passing Site Review: Goal Setting
September 15, 2021 | Selecting Your Organizational Partners
October 6, 2021 | Supervising & Tracking Care Management
October 20, 2021 | Setting Population Health & CQI Goals
November 3, 2021 | Models for Reporting & Tracking Outcomes
November 17, 2021 | Troubleshooting for the Medicaid Site Review
December 1, 2021 | PHP, Billing, and Coding
December 15, 2021 | Sustainability Models
January 5, 2022 | Emergency Services & Walk-in Crises
January 19, 2022 | Risk Stratification & Acuity Tiering
February 2, 2022 | Team-Based Care in Integrated Care Settings
February 16, 2022 | Serving Co-Occurring Diagnoses
March 2, 2022 | Implementing Tailored Care Management
March 16, 2022 | Working with the IDD/TBI Population
April 6, 2022 | Equality, Diversity, Inclusion: Cultural Competencies
April 20, 2022 | OBGYN/Substance Use Disorders (SUD)
May 4, 2022 | Trauma-Informed Care
May 18, 2022 | Mental Health/Substance Use Disorder Assessments
June 1, 2022 | Clinical Consultants: Psychiatrist
June 15, 2022 | Working with Justice Involved Patients/Clients
July 6, 2022 | Addressing Unmet Health/Resource Needs
July 20, 2022 | Improving Patient Access and Engagement
August 3, 2022 | Additional Needs Related to Tailored Plan Launch (July 1, 2022)

Appropriate continuing education credit is offered for live participation in the Tailored Care Management Learning Collaborative sessions. A certificate of completion is awarded for viewing of recorded sessions. It is recommended that AMH+ and CMA organizations save NC AHEC educational certificates for the site review.


Tailored Care Management, Continuing Professional Development

NC AHEC provides monthly Tailored Care Management related course offerings to both AMH+/CMA candidates and the community. Educational events are hosted by NC AHEC and regional AHECs, and various types of continuing education credit, depending on the topic. Events are offered at no cost to the AMH+/CMA candidates passing the certification desk review. There is a registration/credit fee for community members desiring to learn more about Tailored Care Management topics. Webinar platforms are provided for all events.


For questions about NC AHEC Tailored Care Management (TCM) Practice Support, contact Liz Griffin at

For questions about NC AHEC Tailored Care Management (TCM) Continuing Professional Development, contact Scott Melton at

Collaborative Learning Sessions and Recordings are for TCM providers who have passed the desk review, and are offered free of charge. The community may participate in the Continuing Professional Development events for a fee.

Advanced Medical Home

Advanced Medical Home Coaching Opportunities

Looking for the AMH Tier Support Tool? Download here.

A primary care practice is eligible for 1:1 coaching from the NC AHEC Practice Support team if they are (1) in network with at least one Medicaid PHP and (2) not activity engaged in AMH support from one or more CINs and one of the following:

  • Tier 2 *essential practice
  • Tier 3 *essential practice wanting to reassess appropriate Tier level and/or strengthen Tier 3 readiness and performance
  • Tier 2 or 3, health system affiliated, or owned practice located in medically under-resourced community

*Essential practices include independently owned primary care; FQHCs; RHCs; and local health departments with primary care.

Advanced Medical Home Webinar Series

In December 2020, a new Medicaid Managed Care webinar series on the Advanced Medical Home (AMH) program was offered to Medicaid primary care practice staff and clinicians. The series was designed to support practice managers, quality improvement professionals, care coordinators, and others responsible for meeting the NC Medicaid AMH Tier 2 or 3 requirements. You can find recordings, slides, and transcripts of all the topics below.

North Carolina AHEC is now offering two additional webinar series on Medicaid Managed Care topics in partnership with the North Carolina Department of Health and Human Services. Learn more.

Webinar Recordings, Slides and Transcripts

December 10, 2020 | Series Kickoff: Recording, Slides, Q&A and Transcript
January 14, 2021 | Tier Support Tool: Recording, Slides, Q&A and Transcript
February 11, 2021 | AMH Glide Path: Recording, Slides and Transcript
March 11, 2021 | Transition of Care at Managed Care Launch (Crossover): Recording, Slides and Transcript
April 8, 2021 | Transition of Care Part 2:  Ongoing Transition of Care Post Launch: Recording, Slides and Transcript
May 13, 2021 | AMH Refresher: Recording, Slides and Transcript

Medicaid Managed Care

Medicaid Managed Care
Webinar Series

The North Carolina Department of Health and Human Services Division of Health Benefits and North Carolina AHEC are offering an evening webinar series to help providers, practice managers, and quality managers succeed with Medicaid Managed Care.

Hosted by Shannon Dowler, MD, Chief Medical Officer of the NC Division of Health Benefits, the Medicaid Managed Care webinars on the 3rd Thursday of the month are dedicated to bringing you late breaking information and guidance on NC Medicaid’s transition to Managed Care.

Topics will vary, but each session will include an open question and answer period. Upcoming topics will include: pharmacy and durable medical equipment, behavioral health, transitions of care, specialized therapies, quality measures, network adequacy, provider directory, billing, incentive payments, clinical coverage policy updates, and more. 

Medicaid Managed Care Webinar Series

Hosted by Shannon Dowler, MD, Chief Medical Officer, NC Division of Health Benefits. Moderated by Hugh Tilson, Director of the NC AHEC Program.

Every 3rd Thursday of the month from 5:30-6:30 PM
*Please note the 1st Thursday webinars will return in March 2022.

January 20, 2022 | Medicaid Hot Topics
February 17, 2022 | Medicaid Hot Topics
March 17, 2022 | Medicaid Hot Topics

Webinar Recordings, Slides and Transcripts:

October 21, 2021 | Medicaid Hot Topics: Recording and Slides
November 18, 2021 | Hot Topic Updates / Behavioral Health Collaborative Codes: Recording and Slides

Access an archive of webinar Recordings, Slides and Transcripts here.

Webinar Series: Quality & Population Health

This series, formerly the Advanced Medical Home (AMH) Webinar Series, is designed to support providers, practice managers, quality improvement professionals, care managers, and clinically integrated networks (CINs). Join us for one or for all!

Hosted by Hugh Tilson, Director of the NC AHEC Program

September 9, 5:30-6:30 PM | AMH Quality Measures (Specifications, Baselines, Targets)/Medicaid Statewide QI Projects FY22, Provider Supports: Recording, Slides and Transcript
October 14, 5:30-6:30 PM | Integrated Care for Kids (InCK) / Healthy Opportunity Pilots:  Impacts to AMHs: Recording and Slides
November 16 December 9, 5:30-6:30 PM | Advanced Medical Homes: Incentives Plan

Virtual Statewide Quality Forum

The North Carolina Department of Health and Human Services Division of Health Benefits and North Carolina AHEC, in conjunction with the five Medicaid managed care health plans, hosted a Virtual Statewide Quality Forum in October 2021 to help providers, practice managers, and quality managers succeed with Medicaid Managed Care quality initiatives.

Topics included DHHS NC Medicaid Managed Care Quality Strategy, statewide performance improvement initiatives for SF2022 (childhood immunizations, diabetes control, timeliness of prenatal care), Health Plan and AHEC Provider Supports, and Quality Measure Data and Reporting.  The session also included a question and answer forum for participants.

Access the October 12, 2021 Recording, Slides and Transcript.

Virtual Office Hours for Providers

Medicaid Transformation Provider Services and North Carolina AHEC conducted a series of Virtual Office Hours for providers March through September 2021. These sessions offered an interactive format for providers to ask questions on a variety of Medicaid Managed Care topics. View past Virtual Office Hour recordings, slides, and transcripts below.

March 2, 2021 | Provider Directory: Recording and Slides
March 25, 2021 | Carolina Access Health Equity Payments: Recording, Slides, Transcript and Q&A
April 22, 2021 | Provider Directory, Enrollment News, and Hot Topics: Recording, Slides, Transcript and Q&A
May 27, 2021 | Medicaid Managed Care for Vision Services : Recording and Slides
June 24, 2021 | Medicaid Managed Care for Hearing Services: Recording, Slides and Q&A
July 22, 2021 | Medicaid Managed Care Hot Topics: Recording, Slides and Transcript
August 26, 2021 | Supporting Members Transitioning to Medicaid Direct: Recording, Slides and Transcript
September 23, 2021 | Medicaid Managed Care Hot Topics: Recording, Slides and Transcript

Health Plan Virtual Meet & Greets

Health Plan Meet & Greet live sessions concluded on April 8. View our recording archive here.


December 11, 2019

Carol Stanley

As the Medicaid Transformation Manager for the NC AHEC Practice Support team, Carol Stanley leads AHEC educational initiatives for NC Medicaid Managed Care. Carol brings [...]



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