Population Health and Case Management

Kintegra’s Population Health and Case Management services identify patient populations within Kintegra and focus on enhancing quality, providing resources and improving health outcomes.

Linkage to Care and Resources:  Working in collaboration with local hospital system, Kintegra Case Managers identify  uninsured patients who do not have a primary care provider, and help to link these patients to care at Kintegra.  By identifying social determinants of health that can contribute to this populations’ health challenges, the team can  link them to key community resources, provide referrals to HealthNet Gaston, and work with the diabetic population on A1C control.

Leading Change:  At-Home Care Pilot: Kintegra has been selected by the National Association of Community Health Centers (NACHC) as 1 of 20 Community Health Centers in 16 states  to participate in this ilot program which offers patients their own self-care tools and remote patient monitoring to prevent unnecessary health problems.  Patients received BP cuffs, scales, A1C testing supplies, fecal occult testing kits and thermometers. Case Managers work with this population to help manage weight, BP and A1C. The project is called, “Leading Change: Transforming At-Home Care”.

Panel Manager Team: Team of RN’s and LPN’s that are embedded in all our Medical Clinics to provide care coordination, improve quality and enhance the patient experience. They work closely with all of our partnerships and directly with patients to improve patient care. They work closely with our providers to complete Medicare Wellness visits and Transitions of Care


Maternal – Child Case Management

Kintegra has partnered with the Gaston County Health Department since 2011 to provide care management services to high risk pregnant women and children.

Care Management of High Risk Pregnancies (CMHRP)

Previously known as Pregnancy Care Management Program (OBCM)

This program identifies medical and social determinants of health that increase the risk for preterm birth and low birth weight infants. By engaging those at risk, we are able to provide access to timely prenatal care, individualized prenatal education, and provide the support needed to overcome barriers throughout the pregnancy and postpartum period.

Care Management of At-Risk Children (CMARC)

Previously known as CC4C

This program provides care management to all families of children birth to age five with Special Health Care Needs, exposure to toxic stress in early childhood, children in foster care, those requiring NICU hospitalization, and children identified with “potentially preventable” hospital or healthcare costs. By engaging the families of these children we are able to assess and identify physical, behavioral, social and developmental needs that can be overcome with access to providers, services, and individualized family-centered education.

Traditionally provided only by the Local County Public Health Departments, in Gaston County, CMHRP and CMARC are contracted with the Maternal – Child Case Management Department of Kintegra and are operated in close collaboration and oversight by the Gaston County Health Department.  Others counties’ CMHRP and CMARC programs can be found at their Local County Public Health Departments.

To learn more, contact: jtilley@kintegra.org704.772.4626

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