A Social Worker's Perspective on Solving a Complex Problem

By Morgan Forrester on March, 13 2019
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Morgan Forrester


Morgan is a Community Engagement Manager for the statewide network, NCCARE360, and has been leading implementation on the ground for its launch in Alamance, Rockingham, and Guilford Counties. Over the past few months, she has been leading influencer meetings and strategy sessions working side-by-side with local health and social service providers. To learn more about this program, click here. We asked her a few questions about her experience, her approach to care coordination, and the work happening in North Carolina.


Q: Can you describe the concept behind a coordinated care network?


A: Social determinants of health (SDoH) is a hot topic that you've probably heard about, especially if you work in health and human services. Essentially, our health is determined by much more than genetics – particularly things such as stable housing, financial and food security, and other factors. By coordinating care delivery across health and human service providers, we shift the focus from the system to the consumer. This allows us to address health proactively and truly improve outcomes.


Q: Why was NCCARE360 created?


A: When stakeholders gathered to brainstorm how to move the needle on SDoH, it became evident there was a vital need and unique opportunity to create a coordinated care network for the state. Thus, NCCARE360 was born, connecting North Carolinians to the social supports they need to live a thriving life.


Q: Why is this work important to you?


A: As a former case manager at the local level, I struggled to understand the resources in my community. They were continually changing and challenging to access for myself and my clients. Many times, the “referral” to my clients was in the form of a piece of paper or brochure, putting the onus of accessing supports on the client. It was a frustrating experience for myself as well as my clients. The siloed, uncoordinated approach made it almost impossible to track the referral and outcome for my clients. It always seemed like we were playing catch-up and the burden was great.


Q: What were some of the biggest challenges you saw as a social worker?


A: Prior to coming to Unite Us, I was a program consultant at the North Carolina Division of Social Services in the Child Welfare section where I managed a child abuse and maltreatment prevention grant called the Children’s Trust Fund. My time in that role gave me a bird’s eye view at just how systemically institutions are siloed, even within the same sector. Many times, when conducting monitoring visits with the grantees, we would discuss how they received referrals for their programs and how they sent referrals. Over and over again, there was little coordination, and an immense amount of staff time was spent soliciting and sending referrals. It was hard to witness this burden not just on one grantee, but all 37 across the state. The issue was pervasive. These experiences ultimately led me to pursue an opportunity where I could make a systemic impact to help solve this breakdown in our system of care.


Q: Based on your prior knowledge of the fragmented health and human service industry, how do you think NCCARE360 will bridge the gaps?


A: The NCCARE360 platform is a unique solution that will absolutely transform how health is viewed and delivered in North Carolina from case management to the larger system. The solution of creating a coordinated care network that all health and human service providers can use to make referrals, track services, and close feedback loops is amazing and will truly move the needle. Down the road, we will be able to pull robust data that will help us understand where the service gaps are and what the most requested supports are. I’m excited for the potential to keep consumers from falling through the cracks but also the opportunity to have data on service gaps.


Q: How's it going so far?


A: Socialization for NCCARE360 began in December. We’ve hosted four strategy sessions and four software trainings with hundreds of service providers from Alamance, Guilford, and Rockingham counties. We are continuing to work closely with the local community to onboard and train providers from the five focus SDoH pillars: Housing, Employment, Food Insecurity, Transportation, and Interpersonal Violence as well as other sectors such as early childhood and home visiting programs. 

I am thrilled to be part of this transformative initiative in the state and cannot wait to see users, community-based organizations, and the healthcare system collaborate to better serve North Carolinians!



To learn more about how Unite Us coordinates care:

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