In this episode of the Move to Value Podcast, we continue our conversation with Julie Quisenberry of Coastal Horizons about what care management looks like on the front lines. Julie shares how her team supports patients facing housing insecurity, food insecurity, substance use, and behavioral health challenges, while also navigating language barriers and limited resources.

From expanding Hepatitis C treatment programs to building bilingual services and training staff in cultural competency and trauma-informed care, Julie offers a candid look at the realities of delivering whole-person care. She emphasizes the importance of celebrating small wins, collaborating with community partners, and adapting to constant change in Medicaid and tailored care plans.

This episode shines a light on both the challenges and the resilience of care managers working to improve outcomes and support their communities—one patient at a time.

How can we improve? We're always looking at how do we do better, how can we engage people better and what does that look like? So we're always going back and retraining and learning from our mistakes and learning from the mistakes of our colleagues, right, like, how can I share my experience if somebody else doesn't step on that same hornet's nest next time? We just had our TCM audit and how do we grow from that? How do we improve our care? We don't look at it as a bad thing. We look at it as a way to grow because we're not perfect and we're not going to be and we always have room to improve.

Today on the Move to Value podcast, we continue our conversation with Julie Quisenberry, Director of Care Integration at Coastal Horizons, to talk about care management at the front lines. Julie shares what it really takes to deliver whole-person care—meeting people where they are, overcoming language barriers, addressing housing and food insecurity, and navigating a constantly shifting system. She talks about what it really means to support people beyond the clinic with a real-world look at the challenges—and the small wins—that make all the difference

Well, Julie, thanks for sticking around for the Move to Value podcast. I'd like to ask you some more questions, but let I'd like to start with the population about what Coastal Horizons serves. What unique needs do you see and how does care management address these needs in ways that traditional models don't and are there specific challenges, social determinants, you know, housing, trauma, chronic conditions that require a more tailored approach.

Yes. So Coastal again is a very large substance use behavioral health provider. One of the things that we have that we are fortunate to have is we have our Clinica Latina program that does outpatient and is on is geared toward our Spanish speaking population. We have therapists, we have psych providers, MAs and in our primary care practice we also have Spanish speaking provider and Spanish speaking MAs and front desk staff because we've seen a large influx of that population reaching out and accessing care, which historically I think in the behavioral health sense has not been something that that they have done. So our clinical Latina program started out very small, probably about 15 years ago and has grown to like almost triple the size, which is great. And we want to embrace that. And they send, in primary care, send a lot of folks to us because they've gone without health care. And so we have grown, that has grown for us in primary care over the last two years since I've been doing primary care has grown a lot. And so the need for bilingual folks has really grown. So we're really fortunate to have that and even in our kid population expanding our reach with bilingual therapists and bilingual site providers as well. So I think that we've really tried that we will serve anybody regardless of language, because we do utilize the language line. So just trying to make sure that, yeah, that that's probably been the largest population that's grown. You know, we'll we serve. I mean, listen, we are, we'll take if you. We are non-judgmental. You know, whatever your need is, come as you are and we'll figure it out, right? So I think that and if we can't do it, then we we have community partners that we can refer to like if someone has a significant or severe eating disorder, we may refer them to to Chrysalis Center that that's their specialty, right. In primary care we we have taken on we expanded our hep C treatment program. So we have some primary care providers that are sending folks just to us for hep C treatment and then we refer them back to their primary care. Once it's kind of like your OBGYN, you have your baby and then you go back to your primary care. We kind of do that in primary care with hep C and have grown our hep C programs because you know with the opioid addiction and you know, I V drug use, it's just New Hanover County is just like what the right word is, but it it's overwhelming sometimes the volume of patients that we see. We have a very large Medicaid assisted treatment program as well that sees those folks. So we collaborate to ensure that they get their physical health and behavioral health. Social determinants of health are a big deal. As you're probably aware, the Healthy Opportunities pilot ended. We were, We were fortunate enough to be part of that and we're able to serve over 400 clients a month in, you know, housing navigation, first, first month's rent in security deposit, healthy food boxes, interpersonal violence, utility assistance, all the things that that program kind of encompassed and the loss of that as of July 1 or June 30th is significant for us. So we're having to be more creative in how we help people access those services because affordable housing in in our area is just really, really hard. It's not affordable. I mean, it just isn't. You know, I I look at people that I know that aren't struggling with any kind of, I don't want to say disability because that's the wrong word, any kind of issue or or struggling. And you know, making $10 an hour can't live here, they just can't. And so we have a very large homeless population. Coastal is fortunate that we have our path outreach and our port outreach that that specifically work with our homeless population and try to house them. But social determinants of health, we're utilizing like the food banks, we're utilizing Nourish N C. Our Wilmington Health Access for Teens has given out more food boxes, 30 LB food boxes since the end of healthy opportunities than it did in the last six months of the year. So I'm really sad about that and I hate that, but I understand the logic if I were a senator and my constituents weren't benefiting from this very incredible program. Why would I vote yes? I vote yes because it's in my area, but it can certainly appreciate the dilemma that that created in Raleigh, right, like can certainly appreciate that. Hopefully they'll revisit that because it does, It has significant benefits to people. It decreases. It's a non-medical intervention, if you will, to meet people's basic needs. Keeps them out of the hospital, keeps them from going inpatient, keeps them from doing all the things. So we're doing the best we can around that. But we took it was a struggle. We're we're still kind of working through what does that look like and where do we get rent and where do we get people housed so. But we're using what we have in our community and our communities trying to embrace that, the loss of that service. But it's been a difficult transition for us, just our care managers in general. So I guess that's what I would have to say about that.

Yeah, it's it's it's been tough in a in a lot of the places where cost of living is much higher and we've seen that and I I know that New Hanover, you know Wrightsville Beach and Wilmington it it's expensive. Coastal towns typically are expensive so.

And if and if you move to Brunswick or Pender counties, then you lack transportation to get into where the resources are. So it's this double-edged sort of you can move to Pender County if you want, but you can live in Burgaw, which will take you 25 minutes to get, you know, to get here, 30 minutes to get here and depending on the day with traffic could take you even longer. But how do you get here, you know, we have mobile clinics that do Blaine in Columbus County and southern Brunswick County that are doing primary care and behavioral health and substance use services because the outreach and the need is there. But it's hard because. The resources aren't there. We can do all the things, but the resources just aren't there. So it's tough.

Well, in the context of tailored plans, what are the biggest gaps you're trying to close and how are you doing that? I mean, we've talked about physical and mental health and community support and clinical treatment. What are, what are some of the gaps that are there you guys are working on?

I think one of our biggest gaps, the one that comes to mind right now with my tailored planned care managers is finding a Medicaid dentist for adults has been really difficult in our area. You know, we're referring like to ECU and other places.

That's been one and that just comes up because we had a conversation about it yesterday. Um. So, yeah, so I think that's the biggest gap that we're seeing. We are housing, obviously we just talked in ad nauseam about housing is a big gap for our folks and be able to be housed. I think closing the gaps is just really looking at what what somebody needs and how do we, how do we get there? Obviously, everybody needs an annual physical, so we're working on those healthcare gaps, any annual dental or every six months. But we got to find a dentist first. Kids is a little bit easier because we do have pediatric medicine that take Medicaid. But I think sometimes too the other gap that I see and and I and I think this is true for the standard plan as well as it is for the Tailored plan because on the Tailored plan we are an AMH plus as well as a CMA which means because we were on the standard plan side as an AMH tier 3, so we have this weird hybrid. But I think we're one of only three in this state that do both. One of the other things that we've really struggled with as we have kind of been moving through that. Transportation is another one. You know, trying to find transportation, Medicaid transportation that's reliable. And I can't remember the other one because it's true on the, it's true on the standard plan side as much as it is on the primary care side. But it'll come back to me probably at 2:00 in the morning.

Perfect. Or just give me a call. I'm I'm always awake. Well, so earlier we we spoke about some language barriers and how you guys are are are are successfully overcoming those. So how do you ensure that the care management services are equitable, you know, especially for systemic barriers? And we talked about language, but what about cultural systemic trust? Are there strategies for outreach or adaptations that have made a difference there?

Yeah, I mean, I think we have Spanish speaking care managers as well. I talked about it with our, you know Clinica Latina. We have it with our primary care, but we have Spanish speaking care managers as well and and we have a Spanish speaking community health worker slash extender. And so we do a lot of our director of care management, I will say is probably, I mean, I think cultural competency is something that we all are working on every day, right. But she's probably one of the most culturally competent people that I have ever come across in my professional career in terms of really being mindful of you can't just assume that because someone is a certain way, looks a certain way, speaks a certain language that you understand the culture. And so I think she does a lot of training around that and she's had our Spanish speaking care managers do training with our team as a whole around what is culturally, what does that look like because you are kind of in there is a very large difference in how they view behavioral health services versus how we view it. And and so we've done some training around that. We, you know, try to have really open door policy when someone is struggling with what does that look like, what do I, what do I need to do different reaching out to our colleagues within our system that somebody may have had experience working with someone who is, you know, first generation. You know, we just had this happen, someone who's first generation from Korea and and trying to navigate just our system as well as trying to navigate the language barrier and all of the things and what does that look like? You know, then there's the educational piece is, are we giving people things that they can read? Do people know how to read? You know, I sat in the lobby last week and went through our consent forms with someone because they were humble enough to tell me as I was walking there. I said, hey, how are things going? And they kind of looked at me. I said, well, what's going on? And sat down and were humble enough to tell me that they couldn't read it. So we our front desk handed somebody a packet of paper to fill out without even. And this human sat down and just sat there and I'm like, I just happened to be blowing through on my way to my office. And so I think we have to just sometimes take a step back and remember that are we giving people things? Are we asking the right questions, are we, are we doing things in a way that makes sense and and and we and like I said, I think we always have room to grow in that area. We are never going to be perfect at that and we are going to fall into the pitfalls because it's human nature, right? And we're we live in our space and they live in theirs. But how do we, how do we work in that space where there's mutual respect and mutual understanding and respecting whatever that is? You know, we had a care manager come in and they went into a house and the mom asked her to take her shoes off and she didn't want to take her shoes off. Well, that's their home. You're walking.

Into someone's home and having those hard conversations of that's what they expect you to come in your home. And so how do we work through that? And so I think we take it as it comes and we do the best that we can and are always mindful. Like I said, our director does a really good job of trying to make sure that she's always talking about that people don't look like that, the same people don't always look like you. They they may, but they may act very differently. Their home life, everybody comes to the table with whatever their life brings them and their life circumstances bring them. And we have to remember that while we bring those, so does every single person and we always work from a trauma-focused perspective because whether you choose to believe it or not, everybody's had some sort of trauma in their life, myself, you, everyone. And so we kind of always work from a trauma-focused lens, whether they choose to share what that is, but you can use the skill set that that you know with being trauma-informed and we train in that and we train around that. Whether someone chooses to disclose what that is or not, you can use that lens by which to work from and then always coming at it from using motivational interviewing to get folks to to engage with you. So we do a lot of training around that. So we just kind of, we're always, how can we improve? We're always looking at how do we do better, how can we engage people better and what does that look like? So we're always going back and retraining and learning from our mistakes and learning from the mistakes of our colleagues, right, like, how can I share my experience if somebody else doesn't step on that same hornet's nest next time? So we do a lot of that and and we believe that that we just had our TCM audit and how do we grow from that? How do we improve our care? We don't look at it as a bad thing. We look at it as a way to grow because we're not perfect and we're not going to be and we always have room to improve. So that's a very long answer to your question.

No, that's a that's a great answer and I think this this podcast is one of those mechanisms for for sharing that information so that we can all all learn from each other. You know my my family's been generations here and I've worked in healthcare for 10 years and I still don't know how to fill out the forms. So I. I I've had great, great sympathy for some of the folks who who who do come here. They're first generation and we see a lot of the kids helping their parents, you know, translate the forms and it's it's a challenge and I I hope that I'm glad, I'm glad that you're, and you over at Coastal, you guys are really taking that initiative because I do think that's so important that's.

Yeah, most of our paperwork is is in Spanish is when you get the one-off languages that we don't necessarily have. All of our paperwork is in Spanish and in English. So, but it was a good opportunity. Like I said, when I blew through last week was a good opportunity for us to retrain our front desk and not assuming that you hand somebody the packet to fill out and that they're just going to go sit down and fill it out. It's asking the next question like, hey, do you have any questions about the paperwork? Is there anything that you would need assistance with? Just let us know and somebody may or may not ask, but you could see the look on this person's face was just like I knew the minute I walked through. I knew that there was something going on. So it's a good opportunity for us to go back and retrain people and paying attention to the social cues, because sometimes it's the non-verbal as much as it is the verbal. Right, so it was a good opportunity and a good learning experience for us, so we're always going to try and do better.

That's great. Well, where have you seen wins like improved outcomes, better engagement, smoother workflows and and what are the friction points? So what what's the good and the bad that you're that you're tackling? Is it staffing integration follow through or or is it something else for that one?

So I think we have lots of wins every day, right? Lots of wins. Somebody gets their own house. Somebody gets accepted by Habitat for Humanity. Somebody, somebody decides today is the day that I'm going to walk into coastal. I'm going to engage in treatment. Somebody decides today that you know what, I'm ready to go and and and and have the physical. So we take the wins as they come and it's it's not looking for the big wins. It's also looking for the small wins because the small wins are the ones that make the biggest difference in the long run, right. So we see those every day. Our care managers, we celebrate our wins in our monthly staff meetings.

I agree. What advice would you give leaders trying to build or improve care management systems in other communities? What do you wish you had known? What are key partners, cultural shifts, infrastructure elements that make the difference, and what can go wrong? It's a lot of lot of questions.

Yeah, I mean, I think the biggest advice I would give is you you have to roll with the changes because what you think you know today, you're not going to know tomorrow. And I think it's the nature of this service. That’s hard change is hard, right? And so just when you're you have ten care managers and they all think they've got it and here we come and say, guess what, y'all, we told you, you know that you were going to do this and now you're going to do that. I think communication for us has been the key of really communicating with our team, being transparent with our teams around and not, you know, just handing somebody a provider manual. But those those monthly Meetings where we're sharing updates has been helpful. I I I will say again, celebrating the little wins because again, this job is hard on a good day and sucks on a bad day. And so celebrating the little wins with people and really celebrating people's successes, both personally and professionally. Because if, you know, we had one of our extenders just got certified as a community health worker. Let's celebrate that, right? That's a personal win for her and that's a professional win for her. So what what people are willing to share and how do we do that to building a really cohesive team? I think the pitfalls are the pitfalls are getting sucked into some of the some of the stuff when you get on the state tag Meetings or whatever. And I have told my, you know, there was all this stuff around the raid and all the things and I hear that and I appreciate that, but I can tell you that you have to pick your battles. What sort are you willing to die on? And so that's what we've that's what we have at Coastal has decided to here's what we're willing to argue for, here's what we're not willing to argue for. And then I have buy-in. I'm fortunate enough that I have buy-in from my leadership. That our COO and our seat president, and CEO have bought into the service and bought into how the service helps everyone at Coastal. Like if they're working with a with a psychiatric provider or a therapist that really has been I think instrumental in us being able to grow our team the way that we did. Um. And so I'm we're really lucky in that regard to be able to build that. So I think for me it it really is celebrating the little wins, communicating and really building a culture of trust with your care managers and a a sense of team and camaraderie that they can they they can ask one another questions and then from a leadership perspective, is getting buy-in from your leadership? Why is this service important? How is this service going to benefit our other programs? And if you have that, then I think you can have a successful program.

Buy in seems pretty easy for me. I mean, I don't see how you couldn't because of the difference that it makes so. I'm going to give you a blank check and full freedom to redesign care management from the ground up. What would you build or invest in to make a system that's more humane, efficient, or scalable?

That's a loaded question. I don't know. I'd need to think about that. As my boss says, I'm going to give you my best answer, not my first answer. But if I have to give you my first answer, what I would say is that if I had to do it again, and we could build it from the bottom up. The collaboration in building the service needs to start with providers, the tailored plans and the state all at the same table and developing a service where there is room for everybody and that one group or the other isn't driving the bus, that everybody has a seat on the bus and the driver is some independent person. Because I think that everybody has is motivated by their own roles in this. And the design initially was that the state was driving the bus and then the LMEMC is kind of come over and then they start driving the bus and then the providers have their version and they're driving a different bus. So it's getting everybody on the same page and building it from the beginning about what the expectation of the service is, and then let's stay with what that expectation is. Let's not keep adding things on to it because, oh, we've got care management. We can just add that to it, which is what it feels like has happened. And that doesn't work. You can't ask people to do more with less, right? But let's make it a realistic service that benefits everybody. And they're using the model. Ironically, my my colleagues at TASC, because we we have a very large presence in the juvenile justice and TASC system, they're talking about using the TCM model for TASC. Well, somebody within the in the justice system needs to understand what TCM looks like because you that doesn't translate to this group. So, I think if I could build it up, it would be communication. It would be having a seat, everyone having a seat at the table and an equal voice at the table.

That would be nice. Well, Julie Quisenberry, thank you for joining us today on the Move to Value podcast.

Well, thank you for having me.