Author: Brooklyn Miller

Mitigating the Risk for Falling through the Cracks: Strengthening the Census Response Rate

The Census.

In capturing data on everyone once every decade, the Census is a handy tool on which many of us base our research, programming, and communication. The Census has been around for 117 years, and every decade we see the stark differences in our composition from the decade before. Across many dimensions, the Census measures the pace of change for the country as a whole, each state as a whole, and any local community. In order for us to react to our changing surroundings, we must first know in what ways it is changing—this is the value of the Census.

Aside from the value of the Census for our research, programming and communications, it is also a powerful tool for determining where many federal, state, and local resources are allocated. As the most reliable composition of the population, Census data provides the foundation for distributing more than $675 billion in federal funds each year to communities across the United States to support important programs—including housing, education, transportation, healthcare, and employment. Census data is also used to re-establish the boundaries of congressional and state legislative districts, in addition to other local and state political boundaries, all structural means of increasing representation.

As of today, April 1, here is where we are as a state:

Self Response Rate for North Carolina: 33%

Rank of NC in the U.S.: 39th

As of March 29th, here are some numbers on hard-to-count populations:

% of Young Children in Census Tracts Average Self Response Rate
Less than 4.1% (542 Tracts) 29%
4.1% to 5.5% (541 Tracts) 30.8%
5.5% to 7.2% (541 Tracts) 31.2%
7.2% and above (541 Tracts) 29.4%

Young Children – 5.9% of NC population ages 0-4

% of Foreign-born Residents in Census Tracts Average Self Response Rate
Less than 2.9% (542 Tracts) 28%
2.9% to 5.7% (541 Tracts) 30.4%
5.7% to 9.8% (541 Tracts) 31.1%
9.8% or higher (541 Tracts) 30.8%

Immigrant Population – 7.9% of NC population is foreign-born

% of Minority Residents in Census Tracts Average Self Response Rate
Less than 14% (542 Tracts) 30.2%
14% to 28% (541 Tracts) 32.6%
28% to 50% (541 Tracts) 30.7%
50% or higher (541 Tracts) 26.9%

Minority Population – 34% of NC population is American Indian, Asian/Pacific Islander, Black, or Hispanic/Latinx

% of Residents in Census Tracts with No Internet Average Self Response Rate
Less than 12% (541 Tracts) 35%
12% to 21% (541 Tracts) 30.4%
21% to 31% (541 Tracts) 28.2%
31% or higher (541 Tracts) 26.9%

No Internet – 21% of NC households do not have Internet at home

For more data like this, please check out NC Demography’s Census Tracker:


As an organization that works in public policy alongside communities and community partners, the ncIMPACT Initiative uses Census data all the time. A question we’ve been asking ourselves is: how can we all do our part to make sure this year’s North Carolina count is as accurate and complete as possible?

Here are some ways that might help you amplify the importance of the Census within your reach:

  1.  Use your social capital. One example of using your social capital, or your networks and connections, is by tweeting, sharing, or blogging about the Census on your social media platforms. Share the related content of others and make sure to follow any trending topics by using a hashtag on Twitter (#Census2020 is a popular one on Twitter).
  2.  Talk about your own experience filling out the Census. One thing you can do to spread awareness about the Census is to personalize it. Talk about your experience with the Census, whether that is through social media, newsletters, and everyday conversation (most likely through phone calls or Zoom calls, in our current world of social distancing).
  3.  Intentionally reach out to hard-to-count-communities. Leverage your relationships with organizations and communities that work directly with hard to count communities. For those who run these organizations, be intentional about encouraging the Census completion to your program participants and communities. Hard to reach communities include:
    • Young children under age 5
    • Hispanic or Latino individuals
    • American Indian/Alaska Native individuals
    • Black or African American individuals
    • Frequent movers
    • Renters
  1. Know the numbers. While it’s important to tell personal stories and make an individual case for filling out the Census, it is also incredibly important to emphasize what is at stake, including the number of dollars. More than $1.5 trillion in federal funding to state and local governments is distributed based on Census data – that’s a lot of dollars, and the number may help you make a compelling case for completing the Census.

We challenge you to spread the word about the Census and its great importance today. The link to respond to the Census can be found here:  

Emerging Healthcare Technologies in the Time of COVID-19

The pandemic we are currently facing is challenging traditional means of healthcare and highlighting the need for greater capacity for telehealth. In this current and unprecedented moment, the ncIMPACT Initiative aims to keep our partners and stakeholders informed by starting data-driven conversations and connecting you with resources that can boost your work – now more important than ever as COVID-19 continues to spread.

When ncIMPACT sought out new opportunities for improving health outcomes in the state of North Carolina for a recent project, we explored the potential of emerging technologies and methods of data collection in the health arena. Our work included interviewing 25 statewide and national health experts, and our findings continue to surface as relevant. Our experts pointed out several advantages to telehealth that have surfaced as critical during COVID-19.

Telehealth’s Advantages

  1. Screening patients remotely prevents the need for an in-person Doctor’s visit in which a symptomatic person exposes medical professionals and the public. With a virtual screening, physicians are able to instruct on next steps, including an in person visit with protective procedures if necessary.
  2. Routine care and check-ins can be provided to those living with chronic illnesses to prevent risking exposure. Many follow-ups and regular appointments can be done via telehealth, aiding in keeping those most vulnerable to complications in their homes.
  3. Telehealth models protect healthcare workers from coming into contact with as many potentially infected patients. Not only is it a preventative measure, but expands the capacity of providers. As there are less providers able to care for patients due to being infected, telehealth allows the physician to continue working if they choose to do so while quarantined.
  4. Telehealth will be vital to responding to mental healthcare needs during this time. Our capacity was already strained before COVID-19, and it undoubtedly will face new demands during and after the pandemic. Many people are increasingly facing health challenges and economic challenges, and are often facing these challenges as they are isolating themselves to flatten the curve.



Making Telehealth Work

As more telehealth methods are developed, the community will need to be integrated into the new language and setups of technological systems and data collection methods used by providers. One health expert from our qualitative interviews noted the importance of transparency in order to know what “goal we’re shooting for.” Transparency entails having “conversations with clients, providers, [and] payers,” and making information available to them. To make the technology work for the community, the respondent said, we need to “set up accessible models with a clear sense of what we intend to get out of them.” As many people are shifting to this new model, transparency and communication about telehealth models and the anticipated outcomes is vital to create trust between the patient and the provider.

Barriers to Accessing Telehealth

Telehealth offers many life-saving solutions during a time when person-to-person contact can be potentially deadly. However, we must recognize that these models of healthcare often require access to resources—financial resources to pay for the services if uninsured or uncovered and insurance models that give parity to telehealth services, physical resources (such as a computer) to access telehealth, and connectivity resources to have internet access. For example, North Carolina has a broadband access rate of 68%. This is just one requirement for accessing services, and around 32% of households do not have full broadband access. As we continue to talk about the vitality of telehealth, we must remember that there isn’t equitable access and then work to achieve it.


The Dos and Don’ts of Working in Rural Communities

North Carolina’s demography represents a high concentration of rural areas. In fact, there are 80 counties with an average population density of 250 people per square mile or less (NC Rural Center, 2016)

Those working in rural communities often come across situations in which it may be unclear what the next step is or how to go about that next step. The following categories represent different aspects of working in rural communities from a presentation given on January 24, 2020 by Calvin Allen, Maureen Berner, Anita Brown-Graham, and Brooklyn Mills.




  • Avoid personal interactions for convenience
  • Assume norms around communication
  • Assume choice, power, ability, or resources: Either that folks don’t have them or that they do


  • Develop maximum opportunities for personal interactions. Physically immerse yourself locally as much as possible. Face to face interactions matter for trust building and learning the people and organizations in the community.




  • Create a perception that your expertise is greater than community expertise
  • Devalue input from the community—they are the experts of their own community
  • Come in with a set plan without the expectation to adapt


  • Treat the community as a true partner

Involve local community members as experts, thought leaders, and partners, not research subjects. Their input will be invaluable to ensuring your project’s success. Take their feedback and suggestions to heart. Compensate them for their time, if possible.




  • Focus solely on scholarly research outcomes
  • Use community members as research subjects
  • Let parameters of funding be SOLELY in control


  • Intentionally address local needs and values obtained from research findings

Be serious about addressing community needs and improving local quality of life. Your work may well lead to important publications in scientific journals, but it is not the responsibility of community residents to help researchers achieve that. They are motivated to participate to make things better in their community.




  • Assume norms and systems of rural communities
  • Assume that you have the knowledge required
  • Assume that just because models worked in other similar settings, they will work here.


  • Be prepared always to learn and shift

Recognize the limited knowledge of the researcher about place-based economic and social factors influencing program and service use in rural areas. Don’t assume you can always import models that have worked in urban settings.




  • Forget to fully wrap up a project with a future sustainable plan for the community.
  • Have an end goal of using information purely for academic purposes. Consider developing products that can also be used by the community


  • Leave a legacy of enhanced capacity and sustainability

Enhance skills, competencies, and social capital among community residents. It is the researcher’s responsibility to develop local capacity to sustain interventions and intervention evaluation after the initial research is completed and there is no more funding.




  • Assume that your data speaks for itself
  • Use data-oriented language that is not accessible
  • Expect that things will always go smooth sailing


  • Tell a story with the data
  • Be open about the fallibility of data
  • Be ready for questions
  • Be honest when you don’t know the answer

Find a way to connect with communities around authentic stories of what’s going on. Make sure to go beyond the numbers.



Drawing provided by: Hope Tyson

Impacts of Safety Nets for Families on Health Outcomes

As we continue to explore our findings from our Health Outcomes qualitative research interviews that we conducted in the summer of 2019,  we wanted to highlight the importance of children’s health in moving the needle towards health improvement. When we look at moving the needle toward  health outcomes, a natural place to address future outcomes is by addressing the need for investment in children’s health. Poor childhood health leads directly to poor adult health, which eventually contributes to a generational cycle of poor health within families. The 25 experts that we interviewed advised that one of the biggest impacts on childhood health is the ability to support families through health and human services safety nets.


Image result for health children


The experts that we interviewed reiterated that the key to improving population-health indicators in the near future AND in the distant future lies in improving our children’s social, economic and physical conditions. Childhood health outcomes will trickle into the adult-health outcomes as generational changes occur. Safety nets, such as nutritional aid, income supports, access to healthcare, and housing assistance, provide parents the opportunity to focus on their child’s well being instead of economic hardship. Without an increase in safety nets, the outcomes can be expected to be exacerbated and the chances of climbing the economic ladder are slim. This then creates a cycle of generational poverty, creating family hardships that we know is impacting children’s health.


“There is a large and growing population of people who have played by the rules, but cannot afford above a poverty-level existence,” said one expert. “This is affecting their kids. They have no health safety net and are often living in multi-generational households.”


Social safety nets must be well developed for families with children. One of the biggest influences on health outcomes for children are ACEs (adverse childhood experiences), which can affect health outcomes well into  adulthood. These experiences include physical abuse, sexual abuse, living with a parent who abuses drugs, and similar instances of household dysfunction. According the data, (American Health Rankings, 2019), one out of four children in North Carolina experience ACEs which have been found to be major risk factors for alcoholism, drug abuse, depression, and suicide attempts.8 Experts explained that children experiencing three or more ACEs have a greatly increased risk of health issues. The chart below displays  the frequency of ACEs experienced by North Carolinians under the age of 18 by severity of ACE frequency.



Adverse childhood experiences, such as abuse, drug use in the house, and household dysfunction, are likely to occur in households with economic hardship. While the aim is to help people transition out of hardship and climb the economic ladder, in the meantime, health experts suggest that safety nets must be in place. Not only can these safety nets in the form of services increase the chances for economic mobility, but they also have a direct impact on possibly preventing adverse childhood experiences.


“Bottom line: there are fewer opportunities for children in cycles of poverty to grow and realize full potential,” offered one expert.






Ann E. Austin and Harry W.B. Herrick, The Effect of Adverse Childhood Experiences on Adult Health: 2012 North Carolina Behavioral Risk Factor Surveillance System Survey (2014), 6.


Broadband’s Impact on Economic Development: A Lack of Access to Social Capital

Regions across North Carolina have had significantly varying paces of economic development. Social capital levels offer one lens through which to view these regional disparities. Economic development of a given place can greatly depend on the presence and impact of social capital, which includes social culture, norms and collaboration that promote development activities and possible economic reform.

Social capital can be used and leveraged to achieve the goals of a collective group with an outcome of more economic capital due to connections. Social capital increases the efficiency of social exchange, allowing for communication and collaboration to occur. There are three types of social capital that can be leveraged: bonding, bridging, and linking. Bonding, or in group cohesion, refers to the relationships built among individuals with characteristics or group membership in common.  Bridging, or out of group cohesion, refers to relationships built among individuals, communities, or groups with differing background characteristics or group membership.  Linking is an extension of bridging capital and includes networks and organizations that provide connections across power dynamics, giving access to more resources.

North Carolina residents with no or low access to quality broadband are missing out on important economic benefits of cultivating social capital through connections (Unlocking the Digital Potential of Rural NC Report 2019). Bonding capital can occur through digital connections, bringing individuals of a group together to increase social connections within a group. Bridging capital could be improved by connectivity via broadband access, because many groups of different backgrounds have difficulty connecting face to face or may not even be in proximity to the other group but could greatly benefit from this relationship. Linking social capital is a way in which many communities connect to more powerful networks, allowing for access to thought leadership, information, and resource allocation through broadband access. Without access to this communication, community voices may be left out of the economic development process and therefore have unequal opportunities. Although economic growth will require extended access to Broadband to attract industries providing jobs, this also impacts communities’ ability to form and leverage social capital to improve economic development at all three levels: bonding, bridging, and linking.

In today’s advanced technological world, many connections occur in ways that are not face to face. Many technological platforms have been leveraged to create more efficient connections, which has strengthened the use of social capital for economic development. However, in the state of North Carolina, there is a broadband access rate of 68%, which is likely a conservative estimate. Full broadband access, a necessary utility to access and leverage social capital to improve economic conditions, holds a promise to increase economic mobility for both groups and entire communities.


American Community Survey 5-year estimates 2017: Access to Broadband

Laycock, K.E. & Mitchell, C.L. Climatic Change (2019) 152: 47. (graphic)

First Stop for Regional Sessions: Kannapolis

Regional Sessions Begin to Inform the North Carolina Strategic Economic Development Plan


On September 19, 2019, the ncIMPACT Initiative hosted the first of eight Regional Sessions to Inform the North Carolina Strategic Economic Development Plan on behalf of the North Carolina Department of Commerce. A session is available in each of the state’s prosperity zones. Please click here to see a complete list of regional sessions and register for the one you choose to attend.


For more information about this project and what you can expect at the regional sessions, please watch this brief video.


The regional sessions will be critical to creating the state’s new strategic economic development plan, which will guide policymakers and practitioners in their work to generate more economic prosperity to the state. We want to hear from you about what works in your region and what additional supports from the state could maximize opportunities. We expect rich discussions with a gathering of diverse stakeholders.


We started our first session in the beautiful Laureate Center with an inspiring message from Mayor Darrell Hinnant of Kannapolis.


We described the process and proposed themes for the plan, then provided a regional data profile for the Southwest Region and received very helpful feedback. One interesting data piece that elicited a lot of conversation was the rate of eligible children not being served with childcare assistance.



These numbers by county can be found here:


We are grateful to local leaders in the Southwest Region who participated. To register for one of the remaining regional sessions, please follow this link:

Accountable Care Communities Offer An Opportunity to Address Healthcare Disparities at the Systems Level

In a previous blog post, which you can find here, ncIMPACT shared information around NCCARE 360, an interdisciplinary referral tool being implemented in the state of North Carolina’s medical care systems. As we continue to research impacts of the health of a community, we find it increasingly important to look at the way data around how changes become integrated with existing cultural norms and daily lives of community members in North Carolina. NCCARE 360 is part of an effort to implement a model of Accountable Care Communities (ACCs).


ACCs aim to address health at the community level through addressing the social drivers of health and looks at health on a systems level to better coordinate healthcare with a wide variety of stakeholders within a community. This coordination includes involving non-traditional partners in health initiatives, such as faith communities and academic researchers. ACCs have an underlying value of authentic community engagement. In the context of the ACC model, it is not enough to go into communities and give out information. Stakeholders must work alongside communities to create a power dynamic that gives community members agency and self-determination. Under the ACC model, the goal is to elevate the voices of community members who are most impacted by health disparities. For example, specific race groups are more likely to experience disparities within population health–those voices need to be amplified within this model.



Health Inequities by Race

In fact, the data suggests that many health initiatives have historically neglected or taken advantage of specific race populations, such as the Native American and African American communities (see Black-White Disparities in Health Care Report, released by the American Medical Association[1]). Racial disparities in health begin even at the stage of conception. African American babies are more than twice as likely to die during childbirth than white or Hispanic babies in North Carolina. While white babies die at a rate of 5.4% in North Carolina (comparable to the Hispanic rate of 5.5%), Black babies die at a rate of 12.4% (see figure below from NCDHHS).



Maternal mortality rates are alarming in general, but when analyzed by race, it is evident that Black mothers have a totally different experience during pregnancy and childbirth than their racial counterparts. In 2013, in the state of North Carolina, the maternal mortality rates for Black and white women was almost the same, with the white racial category making a large jump up in rates and the Black racial category briefly falling. However, since then, the numbers have since diverged once more. Today, a Black woman in North Carolina is 3x as likely to die from giving birth than a white woman. From 1999-2013, Black women accounted for 49% of the deaths due to childbirth in the state of North Carolina, while African Americans make up 22% of the state’s population (

While working with the Kate B. Reynolds Charitable Trust on their targeted health strategies, our interviews with experts repeatedly brought up the importance of cultural competency at the systems level to address disparity. For example, one anonymous interviewee we spoke with mentions struggles with healthcare perceptions for older African American men:

“He grew up in a time where he knew studies were being done on Black people. Telling him he needs to go to the doctor brings up distrust for him. Entering into those large facilities, he’s not inclined to do that. He needs a provider that looks like him and be able to come to a place that feels safe.”


These disparities are alarming and to begin addressing these health inequalities, research and reports indicate that strategically culturally appropriate care, community capacity building, and homegrown community leader involvement will all need to be present as a start to making the state’s health system more culturally appropriate. These non-traditional partnerships implemented in Accountable Care Communities will require a breaking down of walls for everyone involved–silos will need to be removed for an integrated community care system.

For more guidance on implementing the ACC model, please see the following guide, provided by Kate B. Reynolds Charitable Trust and Duke Endowment, visit







Decreasing Cost and Increasing Quality: Value-Based Care Could Improve Communities

Co-Author: David Brown

According to the America’s Health Rankings by United Healthcare, North Carolina ranks 33rd in the country. As the ncIMPACT Initiative works alongside North Carolina stakeholders to solve complex problems, we increasingly hear concerns about how the state’s health outcomes affect community economic vitality. It is important to fit these conversations into the context of the changing health systems around us. As a patient, citizen, and community member, you may hear a repetitive term in this context: value-based care. What is it? What solutions does it promise, and what potential problems could it cause?


What is Value-Based Care?

In a granular sense, value-based care refers to health care programs based on incentives: care providers should have a financial stake in basing their care on patient outcomes rather than the number of tests, procedures, or other interventions (sometimes called volume-based care). In the case of Medicare, where the transition to value-based care is occurring most prominently, the federal government hopes that aligning provider reimbursements more closely to health outcomes will ultimately result in better care for individuals, better health for populations, and lower costs for everyone. Other valued-based reimbursement programs administered by the federal government include the Skilled Nursing Facility Value- Based Purchasing Program and the Home Health Value-Based Purchasing Model. This is part of a steady transition toward value-based care at the national level.


The Challenge of Health Costs

Everyone knows – often from experience – that health care can be costly. Some drivers of health care costs are obvious: investments in highly trained personnel and highly specialized equipment; the chronic nature of some diseases; and the willingness to spend almost any amount to prolong life and avoid pain. Little can be done about these cost drivers in our current system. However, much can be done to control costs by incentivizing preventive care, minimizing complications from chronic diseases, modernizing medical record-keeping to avoid unnecessary tests and procedures, and treating diseases and other ailments that tend to occur together as a single health problem, rather than as multiple.

Transitioning to a system where health outcomes are prioritized over the number of appointments and procedures makes intuitive sense, but there are pitfalls to avoid on the road to value-based care. Measuring health outcomes is complicated and lacks an agreed-upon methodology across providers. Further, a system that dis-incentivizes proliferating appointments and tests runs the risk of denying aggressive care to patients for whom it may be appropriate. In addition, there may be a long learning curve as everyone from major hospitals and insurers to small private practices adjusts to the new world of value-based care. Finally, any change that increases reporting requirements is likely to divert providers’ time away from more patient-focused tasks.

Further, hand-offs between specialists as part of a comprehensive care plan are more likely to be successful than if the patient has to seek out each provider on his own. The ultimate goal of improved health means fewer hospital stays and, in the case of a Medicare or Medicaid recipient, lower costs for the government. And if provider reimbursements are tied to improved health, rather than the number of interventions, the incentives for the provider might be higher for patients with a higher likelihood of improved health outcomes.


The Potential for a Promising Response: NCCARE 360

Advanced medical record keeping will become increasingly important with the move to value-based care. NCCARE 360 is a new statewide coordinated care effort that will electronically track, connect, and refer patients through an accountable care  network. This is a person-centered approach in which community members and providers in North Carolina will have access to:

  • A statewide resource directory
  • A community resource repository
  • A referral platform

Experts have recently established that while around 20% of health determinants are around access to healthcare, the other 80% are referred to as the Social Determinants of Health (SDOH). NCCARE 360 will allow for a team of providers and social organizations to track health outcomes of a patient together, with a comprehensive care plan that works in real time. Not only will the patient be a part of an accountable care community, they will also have access to services not typically associated with medical care: housing services, access to healthy foods, domestic violence services, and other SDOH resources.

Image result for social determinants of health graphic

The promise of cost savings, greater efficiency, and better health outcomes will speed the adoption of value-based care in the coming years, as will legislation and regulations that require it. But providers and patients alike will need to be vigilant to ensure that the dollar-related outcomes are not prioritized over those related to patient health and well-being. NCCARE 360 gives an opportunity to impact health outcomes from a person-centered, community approach, creating accountability. NCCARE 360 will be implemented in every county in North Carolina by the end of 2020.


For more information, visit:


Image result for nccare 360


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