Community Health Partners

Since 1998, Gaston Family Health Services has had a key role in the Carolina ACCESS II Primary Care Case Management program known as Community Health Partners (CHP). The program is funded by Medicaid and is one of fourteen networks with Community Care of North Carolina charged to control Medicaid expenditures for high-risk and high-cost patients. Cost containment is achieved by nurse care managers assessing patients’ needs, identifying and coordinating care plans, educating patients on the appropriate use of services, and promoting patient self-management for various chronic conditions. CHP works in collaboration with the area primary care providers (serving as the patient’s medical home) to implement best practices, evidence-based guidelines, and quality improvement initiatives. There are 47 primary care practices participating in the CHP network serving over 33,000 patients.

Through its role in successfully establishing and operating Community Health Partners, GFHS has created a strong support system for building patient-centered medical homes. CHP has several new initiatives underway including palliative care for patients facing a serious illness, behavioral health integration, pregnancy home for high-risk maternity care, telehealth monitoring and transitioning patients from the hospital to another setting of care.

CHP also administers the Health Check Coordination (HCC) and the Early Intervention Awareness program for both Gaston and Lincoln Counties. HCC follows up with parents of Medicaid-covered children who are late in getting a well-child check-up with their doctor. Follow-up is also conducted for childhood immunizations and when a child is a frequent user of the emergency room for non-urgent purposes. The Early Intervention Awareness services are provided through grant funding from the Partnership for Children of Lincoln and Gaston County. CHP staff work with primary care practices and area agencies in Gaston and Lincoln County on having child developmental screenings conducted. Based on the screening results, the CHP specialist works to see that the child is referred for additional testing and therapy services.

For additional information about Community Health Partners, call 704-862-5342.