Quality Improvement

Achieving Improvement and Sustainability

Medicaid Managed Care Performance Improvement Projects (PIPs)

How can NC AHEC Practice Support help you?

NC AHEC provides Quality Improvement (QI) technical assistance at no cost to Advanced Medical Home (AMH) essential Medicaid practices in rural and under-resourced communities (e.g., FQHCs, RHCs, independent practices, local health departments with primary care, and practices in rural areas who are not affiliated with large health systems). While we aim to focus on quality care for Medicaid beneficiaries, patients covered by any payer will benefit from improvement work.

What is NC Medicaid’s Quality Strategy?

NC Medicaid’s Quality Strategy delineates an innovative, whole person, well-coordinated system of care that addresses both medical and non-medical drivers of health and promotes health equity. The Strategy:
• Focuses on rigorous outcome measurement compared to relevant targets and benchmarks,
• Promotes equity through reduction or elimination of health disparities, and
• Appropriately rewards health plans and, in turn, providers for advancing quality goals and health outcomes.

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Did you know NC Medicaid and the Medicaid Health Plans support value-based purchasing arrangements? NC Medicaid requires the Medicaid health plans to offer Performance Incentive Payment opportunities to AMH Tier 3 practices and encourages the plans to offer incentive payments to practices in AMH Tiers 1 and 2. While performance thresholds and payment rates are set by Health Plans, all performance incentive payments must be based exclusively on the AMH measure set and not on measures outside of the set.

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The Quality Strategy also supports Federal Regulation (42 CFR 438.330{d}) which requires Medicaid health plans to conduct performance improvement projects (PIPs) that:
• Are designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction.
• Include measurement of performance using objective quality indicators.
• Include implementation of interventions to achieve improvement in access to and quality of care.
• Include evaluation of the effectiveness of the interventions; and
• Include planning and initiation of activities for increasing or sustaining improvement.

The three NC Medicaid PIPs are:
• Childhood Immunization Status (Combination 10) for ages 0-2 years,
• Diabetes Management (A1C testing and results), and
• Timeliness of Prenatal and Postpartum care.

Statewide data from CY 2019 showed NC Medicaid was performing near or below the national Medicaid median on these PIP measures. NC Medicaid uses the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures to assess performance against benchmarks. Additionally, NC Medicaid noticed a need to improve data reliability and data capture for these areas.

See Quality Measurement Technical Specifications, North Carolina’s Medicaid Quality Measurement Technical Specifications Manual for Standard Plans and Behavioral Health Intellectual/Developmental Disability Tailored Plans for more details.

For the first two years of managed care implementation, NC Medicaid seeks a relative improvement of 5% over the prior year’s NC Medicaid statewide performance for each measure. Go to Quality and Population Health: AMH Measures, Statewide QI Projects to view baseline data and goals.

In support of NC Medicaid’s Quality Strategy and in collaboration with the health plans, NC AHEC (including its nine regional AHECs) applies its QI resources and strategies to support AMH practices and providers across the state as they work on the PIPs and other quality improvement initiatives. In addition, physicians and physician assistants may be able obtain MOC-IV credit if they work on a quality improvement project with an NC AHEC Practice Support coach.

What this Means for Your Practice

NC AHEC wants to support your efforts to succeed as an AMH. AHEC practice support coaches can assist you with workflow redesign, EMR optimization, telehealth, standardizing your approach to quality improvement, identifying data for your patient population, setting realistic goals (including AMH Tier status), etc. Contact us through practicesupport@ncahec.net, and a coach will be in touch with you. We will begin by exploring your current state and improvement needs.

How to Participate

If you are a primary care provider and/or provide prenatal and postpartum care and would like to connect with an NC AHEC practice support coach to assess your practice’s current state and improvement opportunities, please send your request to practicesupport@ncahec.net, and a coach will be in touch with you.

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.

View the videos below to hear directly from Community Health Workers and healthcare providers working in NC about the important role that CHWs play in improving individual and community health.  

Promo Video: View via Google | View on YouTube

Case Study Video: View via Google | View on YouTube

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 gwen.arnold@ncahec.net.

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 practicesupport@ncahec.net 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 www.ncdhhs.gov/divisions/office-rural-health/community-health-workers/community-health-worker-training.

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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.
English: www.ncahec.net/courses-and-events/64098/training-for-the-community-health-work-initiative
Spanish: www.seahec.net/courses-and-events/67188/training-for-the-community-health-worker-initiative-spanish-version–formacin-para-la-iniciativa-del-promotores-de-salud-versin-en-espaol/6

CHW Integration into Advanced Medical Homes:
NC AHEC is developing self-paced online specialty training programs to prepare CHWs and practices for CHW integration into primary care as part of Medicaid Managed Care. Training programs will be released in English and Spanish on a rolling basis beginning February 2022. This service is also supplemented with Practice Support coaches with expertise in CHW optimization within your practice or Advanced Medical Home.

Click on the links embedded in the training program titles below to learn more and to register.

Resource Coordination – English version
Behavioral Health Conditions:  Depression and Anxiety – English version
Working with Clients with Behavioral Health Conditions – English version
Overview of Medicaid Managed Care – English version

These training programs 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 practicesupport@ncahec.net.

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. 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.

July 6, 2022 | Working with Justice-involved Patients/Clients
July 20, 2022 | Addressing Unmet Health/Resource Needs
August 3, 2022 | Improving Patient Access & Engagement

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 Elizabeth.Griffin@conehealth.com.

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

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:
Fireside (Winter)/Back Porch (Spring) Chats on Hot Topics

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

July 21, 2022 | Medicaid Hot Topics
August 18, 2022 | Medicaid Hot Topics
September 15, 2022 | Medicaid Hot Topics
October 20, 2022 | Medicaid Hot Topics
November 17, 2022 | Medicaid Hot Topics
December 15, 2022 | Medicaid Hot Topics

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). All webinars are from 5:30-6:30 p.m. Join us for one or for all!

Virtual Office Hours for Providers

Medicaid Transformation Provider Services and North Carolina AHEC are offering a series of Virtual Office Hours for providers. These sessions offer an interactive format for providers to ask questions on a variety of Medicaid Managed Care topics.

September 1, 2022 at 5:30 p.m. | Provider Enrollment
December 1, 2022 at 5:30 p.m. | Provider Enrollment

2nd Annual 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, will host the 2nd Annual Virtual Statewide Quality Forum on August 11, 2022 from 12:30-1:30 p.m. to help providers, practice managers, and quality managers succeed with Medicaid Managed Care quality initiatives.
This information session will cover the following topics:
Statewide Medicaid Standard Plan Metric Outcomes
AMH Metrics: Maximizing Data Capture
AMH Support

We hope you can join us!

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

Webinar Series: Healthy Opportunities

North Carolina’s Healthy Opportunities Pilot program is an unprecedented opportunity to test the integration of evidence-based, non-medical interventions into the state’s Medicaid program. The Pilots will provide non-medical services to qualifying Medicaid members across four domains: housing, food, transportation and interpersonal violence/toxic stress. Critically, frontline care managers working in Pilot regions will play an essential role in identifying members that may benefit from Pilot services, recommending appropriate services and coordinating their care.

Join us for webinars designed for frontline care managers at the first 3 CINs to participate in the HO Pilots (essential); other frontline care managers serving Pilot regions are encouraged to attend.

In addition to the above webinar series, we are offering the following courses:
Using Motivational Interviewing to Support the Healthy Opportunities Pilots: This course employs effective techniques to quickly build rapport with cases and contacts. Creating a relationship that is non-judgmental and builds on the client’s strengths will allow for a much more productive exchange of information. This technique is critical in working with known COVID-19 cases and contacts. You can register for this course here.

Diversity, Equity, and Inclusion Training – Cultural Humility: This course includes training on Cultural Humility 101 and Culturally Responsive Clinical Care, both of which are required training for Care Management Entities participating in Healthy Opportunities Pilots.  Culturally responsive care is an essential component of ensuring the services individuals and families receive are person-centered, compassionate, and highly effective.  

In addition, building the skills and capacity for diversity, equity and inclusion (DEI) takes time to learn and integrate into patient care.  For this reason, it is highly recommended that HO Pilot participants add to their calendar completing additional trainings, such as Implicit BiasStructural RacismCommunication in Healthcareand Microaggressions

Webinar Series: Dental Provider Educational Sessions

The NC Medicaid Dental Policy Team and the Office of Compliance & Program Integrity (OCPI) Team hosted two (2) Dental Provider Educational Sessions in Spring of 2022 for the following: Dentists/ Specialty Dentists, Office Managers, Front Desk/Insurance Coordinators, Dental Hygienists, and Dental Assistants.

Health Plan Virtual Meet & Greets

Health Plan Meet & Greet live sessions concluded on April 8, 2021.