The New Hanover Community Endowment issued $1.5 million to Community Care of the Lower Cape Fear for creating a plan for a social care network, intended to fill the void left after the state failed to fund the Healthy Opportunities Pilot earlier in 2025.
NEW HANOVER COUNTY — A state-run program allowing Medicaid to pay for non-medical needs like food and housing has been frozen due to a state budget stalemate. However, a $1.5-million lifeline could make way for a local organization to fill in the gaps for area residents now left behind.
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The New Hanover Community Endowment issued in October more than a million dollars to Community Care of the Lower Cape Fear to create a system connecting healthcare providers with local community organizations, to ensure a person’s social needs are met as part of their overall medical care. The network will help residents — especially Medicaid recipients and the uninsured — access services like healthy meals, temporary or stable housing, and transportation. The program will cover a six-county region, including New Hanover, Brunswick, Pender, Columbus, Bladen, and Onslow.
Community Care of the Lower Cape Fear has been around since 2003 and coordinates health and social services to residents, but wanted to start a program of this caliber in the absence of the former Healthy Opportunities Pilot (HOP). HOP was run by the North Carolina Department of Health and Human Services since 2022, but on July 1 this year, $175 million of its funds were frozen. CCLCF was one of three network leads in the state who connected Medicaid participants with non-medical services through HOP.
The program helped over 20,000 people statewide in its infancy, including more than 4,200 New Hanover residents gaining access to housing, transportation, and food services. According to Leigh Quarles, network officer for social and health equity for The Endowment, the grant was identified as a priority due to the scale of HOP’s impact and the risk of losing its infrastructure.
“Studies show that where people live, what they eat, and how safe they are, has a bigger impact on health than medical care alone,” Quarles said. “By addressing these needs, HOP helps New Hanover County residents stay healthier, avoid costly hospital visits, and access essential services.”
Building on HOP’s achievements, The Endowment funding is being used to establish a social care network to connect residents with services previously offered through HOP. Though the grant funds a social care network managed locally, allowing CCLCF to make decisions on what services to provide and how to coordinate them without the state’s input. Unlike the state-run model, limited to high-needs Medicaid patients, the social care network can operate independently of Raleigh funding. As a result, CCLCF can now provide services to Medicare recipients and the uninsured as well.
Leading the transition is Sarah Ridout, the program director for HOP at CCLCF. Ridout pointed to HOP’s success with an evaluation created by the Cecil G. Sheps Center for Health Services Research at UNC-Chapel Hill and showing HOP saved Medicaid an estimated $85 per month or $1,020 annually for every person enrolled between March 2022 and November 2023. By connecting people with non-medical care in the form of services like healthy meals, HOP brought overall costs down by preventing costly doctor’s visits.
The report also revealed a whole-person care approach significantly reduced demand for expensive emergency services, leading to a reduction of six emergency department visits per 1,000 members per month. For those who remained in the program for at least a year, the figure improved to a reduction of 22 emergency department visits per 1,000 members.
“[HOP] was really about increasing health outcomes and improving health care costs,” Ridout said.
While the average savings are significant, they are conservative because costs don’t yet account for the long-term impact of resolving chronic health issues, like asthma and diabetes, which can be worsened by a lack of housing or food insecurity.
The $1.5 million from The Endowment is about preserving work done thus far with HOP and making sure a similar program can be installed while the state budget remains in limbo.
Ridout said work on the strategic planning for the social care network began in October, with the goal of developing a blueprint for implementation over a six-to-eight-month period. Since receiving the grant, the team has focused on convening with community-based organizations — such as Wilmington Area Rebuilding Ministry, which provides free home repairs — nearly every week to discuss lessons learned from the pilot and identify ways to enhance operational efficiency.
Because HOP was a first-of-its-kind experiment for North Carolina, Ridout said the program naturally faced some growing pains, such as billing and invoice delays from large amounts of paperwork. Under HOP, a doctor would refer a patient for a social service, and a local nonprofit would provide it. The nonprofit would then submit an invoice to CCLCF, which reviews and validates the service before billing Medicaid for reimbursement, ensuring the nonprofit is paid.
“There was some administrative burden in healthy opportunities as there should be because it’s the pilot,” Ridout said. “That’s why we’re here, that’s why you have a pilot. We look at those concerns, because we’ve been doing this for years, to see how we can change that. What could we do to potentially shift and streamline that experience for the users and for those that provide the services?”
Ridout noted sometimes the overall system seemed fragmented. A doctor might refer a patient for food services, but if that patient also needed housing, the process to arrange another service might have to start all over again from scratch. Instead in the SCN model, once a person is in the network, it is designed to catch all needs simultaneously.
Even with the development of the social care network, the CCLCF team has continued advocacy to the state for HOP funding to return, with Ridout making clear the intention is not to “put HOP out to pasture.” Since funding was paused in the summer, CCLCF staff have been in frequent communication with the North Carolina Department of Health and Human Services and state legislators to share data from HOP’s first few years as evidence for the program’s return.
For example, HOP has led to the creation of 600 jobs in the Cape Fear and supported more than 110 local farm workers who provided fresh food to participants.
As part of data collection, Ridout and CCLCF are currently working on an economic impact analysis for its six county coverage area. CCLCF’s eventual report will look at how HOP funding acts as an economic stimulus to the region, trickling down from the state to local businesses.
“What the analysis is going to show is the secondary impact of having a social care network that invests in local staffing, workforce development, small businesses supplying the materials, and local farmers providing fresh produce,” Ridout stated. “It’s bigger than just improving the health outcomes of your citizens, it’s looking at what that does for a local economy.”
However, The Endowment is legally bound to only fund initiatives that benefit residents of New Hanover County, due to the conditions set in the asset purchase agreement from the sale of the New Hanover Regional Medical Center to Novant in 2021; $1.25 billion of the sale is what funded The Endowment, which has grown its portfolio to roughly $1.6 billion today. In light of the asset purchase agreement rules, Ridout said the first step is to implement the social care network into New Hanover, then eventually replicating it in the remaining five counties.
As the return of HOP funding is uncertain, Ridout said CCLCF’s experience with the pilot could help the organization get federal dollars through the Centers for Medicare & Medicaid Services’ Rural Health Transformation program. North Carolina is one of several states seeking federal funding to improve rural health care, address workforce shortages, and better connect medical providers with social services through a plan called NC ROOTS.
The Centers for Medicare & Medicaid Services is currently reviewing state applications with decisions expected by Dec. 31. If approved, North Carolina would receive $200 million annually over five years.
Considering the overall uncertainty in funding, Community Care of the Lower Cape Fear’s social network “blueprint” should be ready in 2026, according to Ridout.
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