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A new model led by a partnership among Duke University, UNC Health, and the NC Department of Health and Human Services (NCDHHS) is transforming how to support children’s health and well-being.

North Carolina Integrated Care for Kids (NC InCK) launched in January 2022 for children who are insured by Medicaid or CHIP (NC Health Choice) in Alamance, Orange, Durham, Granville, and Vance counties. A coalition of partners – including families, local organizations, and state leaders in the health, social, and educational needs of children – spent more than two years designing the model.

The NC InCK model (pronounced “ink”) supports integrated care for children by more holistically understanding their needs, supporting and bridging services for children and their families, and investing in what matters most to them. NC InCK builds on Medicaid’s whole-person Advanced Medical Home (AMH) care management model and practice-based incentive programs. NC InCK is bringing in additional data from schools and juvenile justice to supplement existing medical and behavioral health data to better identify children who could benefit from additional care management supports. These children and families will have the chance to work with a family navigator from their AMH or their Medicaid health plan.

The family navigator will coordinate services and supports that the family needs across physical and behavioral health, early care and education, schools, housing, food, public health services, child welfare, mobile crisis response, juvenile justice, and legal aid. NC InCK also builds on AMH practice-based incentive programs and has designed an alternative payment model that rewards participating clinical practices for improving measures of overall health and well-being for children, such as well-visits, screening for depression and social needs, and school-readiness.
“Investing in children is the best way to build a vibrant future for North Carolina,” said Kody H. Kinsley, NCDHHS Secretary. “Supporting the well-being of children and their families is a top priority for the department, especially as we work to recover even stronger from the impacts of the pandemic.”

NC InCK has worked closely with NCDHHS in designing and implementing the model in the midst of the transition to NC Medicaid Managed Care to strengthen integrated care for approximately 95,000 children in central North Carolina in both managed care and in Medicaid Direct (Fee for Service).

“The NC InCK model is bringing together multiple sectors that are critical to supporting whole child and family health,” said Dr. Charlene Wong, NC InCK executive director and assistant secretary for children and families with DHHS. “For example, a physician finds out in a well-child visit that a family is running out of food and that the child is missing a lot of school. An NC InCK Family Navigator can connect the family with SNAP benefits, contact the school counselor, and collaborate to find ways to help the child in getting to school consistently.”

NC Medicaid has played a key role in the development and implementation of NC InCK, building on the whole person care delivery models implemented as part of Medicaid Transformation.

“For several years, NC Medicaid has been advancing the medical home model that is firmly established in North Carolina,” said Dave Richard, deputy secretary for NC Medicaid. “NC InCK offers us an opportunity to share new sources of data with our medical homes and to support local community care team collaboration so medical homes can help better support children and family with complex social and education needs.”

Families, advanced medical homes, care managers, health care providers, and core child service providers can find materials to support children and their practices at

“As a physician serving children who are insured by Medicaid in these counties, I know the challenges of not being able to see the whole picture of what a child and family needs,” said Dr. Mike Steiner, NC InCK medical director and pediatrician in chief of UNC Children’s hospital. “NC InCK will help bring all of these needs and services together to improve children’s well-being.”

“All of the coalition partners have been involved in finding the best way to reach the children in our service area,” said Sarah Allin, NC InCK managing director. “We have taken our time to make sure we are hearing the right voices and creating a model that we believe will work in our communities.”

NC InCK is one of seven InCK models in the country that were awarded up to $16 million dollars in funding from the Centers for Medicare and Medicaid Services for the 7-year model.


This project is supported by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $7,299,227 in 2022 with 0% percentage financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS, HHS or the U.S. Government.

Sonya Sutton,, 919-608-0480 (m); Alan Wolf,, 919-218-7103 (m); Robin Deacle,