People often think of healthcare in terms of doctor’s office visits, prescriptions or paying medical bills.   

But for members of Wilmington-based Community Care of the Lower Cape Fear (CCLCF), healthcare is much more. Social determinants of health can affect up to 80% of our health outcomes, said Casey Merritt, director of care management and population health at CCLCF.   

CCLCF has been providing care management services to six Wilmington-area and surrounding counties (Bladen, Brunswick, Columbus, New Hanover, Onslow and Pender) since 2003. It staffs an on-site health navigator at The Harrelson Center and partners with Cape Fear HealthNet, Carolina Complete Health and others to offer resources to address health and health-related social needs.

“Across all of (our programs), the goal is meeting people where they are,” Merritt said.

“I think it’s really important for people to feel like they’re in control of their health,” she added, “and we can empower them to be in control when they feel really helpless or lost about what next step to take.”  

In 2022, the nonprofit was chosen to oversee the Healthy Opportunities Pilot (HOP) program for the Cape Fear region. 

HOP is authorized under an 1115 Medicaid Waiver, allowing the N.C. Department of Health and Human Services (NCDHHS) to earmark $650 million in Medicaid funding over five years. As a state and federally funded pilot program launched in 2022, HOP was designed to improve health outcomes by addressing social determinants of health – such as housing, food, transportation and safety.  

A study conducted by the Cecil G. Sheps Center for Health Services Research at UNC-Chapel Hill found that the program reduced healthcare costs by nearly $2,000 per participant per year.

“North Carolina does such a really good job of putting together what is considered kind of the first in the nation, ‘all eyes on North Carolina’-type of pilot or model,” said Sarah Ridout, director of community programs at CCLCF and HOP program director. “Because it really is very comprehensive, brings together a lot of key stakeholders that typically have not lived in the same space, but also really addresses several components of whole healthcare.”   

State health department officials paused HOP services last year when the legislature passed a mini budget allocating $500 million to Medicaid costs – falling short of DHHS’ projected need for $819 million. 

Over 31,000 people had enrolled in HOP across three regions in the state, including CCLCF’s six counties.

While it was operational, HOP offered simple solutions that often had an impact on a person’s health. For example, according to Ridout, the program covered low-cost home modifications, such as installing grab bars or railings, to prevent falls in the home.   

In other situations, HOP offered medically tailored food boxes to people with health conditions who lacked access to healthy food.  

According to Ridout and an economic analysis, HOP supported the creation of around 1,400 jobs and generated about $58 million in labor income in the six-county region alone.  

While HOP was active, there were about 40 to 50 community-based organizations in CCLCF’s six-county network.  

When HOP was paused last year, Ridout said the effect was immediate.   

“What we saw right away when HOP paused was people in the program disengage from their health and disengage from their health plans,” she said, adding that CCLCF noted a spike in emergency response needs and pressure on existing resources.   

“Now you’re seeing an influx back into those existing resources from food pantries, from housing,” she added, “So now you’ve got either maybe wait lists, or you’ve got more people waiting for those existing resources, and then what if those existing resources aren’t necessarily tied to health?”  

As a result of the HOP pause, CCLCF began making plans to create a “social care hub” using HOP as a model.   

The organization was awarded $1.5 million from the New Hanover Community Endowment last fall to begin developing the blueprint for the hub, which Ridout envisions being “payer-diversified” and not tied to a single funding stream.

In June, the endowment granted $2.5 million for the continued build-out of the hub. While the grants lay the foundation for the hub’s development, the long-term funding plan is to partner with various organizations.   

The hub would be rooted in New Hanover County to start, with plans to expand to CCLCF’s existing broader footprint, and would follow a “payer partner” model: hospitals, health plans, employers, foundations and local governments could plug into the network, while also defining the population they want to serve and what interventions to target. Community-based organizations would then deliver those services within the network.  

The hub builds off the success of HOP – without duplicating its services for enrollees – by focusing on food, housing, transportation and interpersonal safety.  According to Ridout, the new hub would operate alongside HOP – if the program is reactivated. It’s designed to address gaps left behind by the program.   

For example, the hub would take on the administrative burden for participating community organizations, which was often cumbersome for HOP participants.  

“We want to show not just our N.C. General Assembly, but the nation,” Ridout said, “if you have these targeted interventions, it will reduce your healthcare cost, and it will improve somebody’s health outcomes – that also can help shift policy.”