Patient Risk List Updates for Advanced Medical Homes Tier 3 Not Participating in Integrated Care for Kids (InCK)

The following guidance applies to Advanced Medical Home (AMH) Tier 3 practices who are not participating in the NC Integrated Care for Kids (InCK) pilot project. The InCK project currently includes AMH Tier 3 practices in the Duke Connected Care, UNC Health Alliance and Community Care Physician Network (CCPN) clinically integrated networks (CINs) in the participating counties of Alamance, Durham, Granville, Orange and Vance. For more information on the InCK pilot, please visit NCDHHS’ NC InCK Webpage.

As part of implementing the InCK pilot program, DHHS has added new valid values to the “Priority Population” field in the Patient Risk File layout transmitted from Prepaid Health Plans (PHPs) to AMH Tier 3s and their CIN or data partners. These values identify the Service Integration Level (SIL) for beneficiaries participating in the NC InCK program. 

Only AMH Tier 3 practices participating in InCK (as described above) are expected to utilize the “Priority Population” designations of SIL 1, SIL 2 or SIL 3 for their associated beneficiaries. However, non-InCK participating AMH Tier 3s have the option to utilize these SIL designations when identifying priority members for care management.  

The InCK SIL priority categories are based on data from the Department of Instruction (DPI), the Department of Juvenile Justice (DJJ), depression screening data, benefits claim indicators, care needs screening data and care management data. 

• Beneficiaries designated with a SIL 1 are children that may have an isolated health (physical, behavioral or developmental) diagnosis and contextual risk (socioeconomic, educational, developmental or parent/guardian risk factors) without the intermittent risk of out-of-home placement. 
• Beneficiaries designated a SIL 2 are children experiencing multiple moderate-severity health, Social Determinants of Health, education or guardian risks. 
• Beneficiaries designated a SIL 3 are children who are out-of-home or have a high-risk of out-of-home placement. These are usually children experiencing multiple complex health (physical, behavioral or developmental) diagnoses, as well as educational, Juvenile Justice and Social Determinants of Health risk factors. Out-of-home placement refers to placement in a psychiatric hospital, residential care center, skilled nursing facility, correctional facility, foster care (including kinship care), or juvenile detention.