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Organization: Monarch
Solution:
Insights From: Anna Marshall & Leigh Herring Daughtridge | Published: May 14, 2026 | 
14 Mins
Summary:
Monarch, a North Carolina nonprofit serving 2,500+ members across 19 counties, impacting the lives of tens of thousands of people with behavioral health needs, intellectual and developmental disabilities (I/DD), and substance abuse disorders, chose MediSked by CaseWorthy to power its Tailored Care Management (TCM) program. The TCM team focuses on those individuals with complex behavioral health needs, I/DD, and co-occuring conditions. Since launching in December 2022, automated workflows, built-in I/DD expertise, and real-time reporting have reduced documentation burden, improved audit outcomes, and helped care managers spend more time with the people they serve.
Coordinated Care That Works: How Monarch Powers TCM with MediSked by CaseWorthy
Monarch is a nonprofit provider of behavioral health, I/DD, and substance use disorder services that supports thousands of people across North Carolina. Its mission is to help people live the lives they choose by delivering person-centered care that meets individuals where they are and connects them to the services, supports, and opportunities they need to thrive. Through Tailored Care Management (TCM), Monarch primarily serves individuals with complex behavioral health needs, I/DD, and co-occurring conditions. As a Care Management Agency within North Carolina’s Tailored Care Management model, Monarch coordinates physical health, behavioral health, intellectual disability services, and health-related resource needs for its assigned panel.
MONARCH AT A GLANCE
~2,500
TCM Panel Members
19
NC Counties Served
37
TCM Team Members
Dec '22
TCM Program Launched
The Challenge: Finding a Platform That Truly Understood I/DD
With North Carolina’s Tailored Care Management program set to launch in December 2022, Monarch needed a care management platform it could configure, train on, and roll out on a tight timeline, without losing the depth required to support people with I/DD.
The team ran a thorough vetting process, looking for an out-of-the-box solution that already understood North Carolina’s services landscape, automated workflows with strong reporting and access to raw data, and a vendor that valued the relational side of the partnership.
Most care management systems on the market were built from a behavioral health lens. Monarch needed one that understood the I/DD service array with the same fluency.
Why Monarch Chose MediSked by CaseWorthy
Four things stood out:
- Vendor subject matter experts who knew the populations Monarch supports
- Ready-to-use I/DD workflows that didn't require significant build time
- A genuinely person-centered design
- A high-touch partnership that included participation in state-level meetings
Implementation: Building a “Day in the Life” of TCM
After the selection was finalized, Monarch and the CaseWorthy team met weekly to build to the Provider Manual, design around the member, and stay on top of training.
Configuration and Design
Working from the Provider Manual's documentation requirements, the two teams mapped how workflows should trigger and which tasks made sense based on identified member needs. Process maps helped them piece together a "day in the life" of a member receiving TCM support, which surfaced the functionality the platform needed to deliver. Monarch's IT team layered in a complementary workflow analysis from a data perspective.
Training and Rollout
CaseWorthy led live virtual trainings, with recorded versions saved for future use. Team members were onboarded before TCM's official launch and practiced in a testing environment so they were comfortable with the workflows on day one.
Ongoing
That same train, practice, then go live approach is still used today for new hires and for rolling out updates as the Provider Manual evolves.
Outcomes and Impact
More Efficient Documentation, More Time with Members
As care managers became comfortable with the system, time spent on documentation decreased. Automated workflows pull assessment needs straight into the care plan, which adds both efficiency and accuracy when addressing what a member has identified.
Caseloads have grown since TCM launched, and the automation has helped teams keep pace. Care managers can monitor their active caseload, see engagement status at a glance, and quickly prioritize high-need members when, for example, a hospital alert comes in.
That same efficiency is what allows care managers like Beth Myers to stay close to members like Joel Lewis in Kernersville. Beth meets with Joel in person every month, and through 1915(i) services Joel is building the everyday skills that make independent living sustainable: money management, scheduling, budgeting, and cooking. He works part-time for a Veterans Affairs contractor and has Maxine, a certified emotional support dog, by his side. “It’s worth the effort to connect with someone who can help,” Joel says. “I’d tell them to talk to someone like Beth who can guide them to the help they need.”
Tracking What Matters Most for I/DD and Complex Behavioral Health Population
For people with I/DD and complex behavioral health needs, the outcomes that matter most to Monarch are stability, access to basic needs, and connection to services that support independence. Being able to identify and track gaps in basic needs has become a critical capability and leads to more targeted resources for members.
The well-child visit is a good example. Tasks in MediSked remind care managers to stay on top of annual well-child visits and prompt follow-up with members and families, and Monarch can then report on completion rates. When the assessment shows that a member hasn’t had a visit, or doesn’t have a primary care provider, MediSked automatically generates a task so the care manager can follow up.
Monarch has also used MediSked’s reporting to identify potential services that members may qualify for, including 1915(i) services. By pulling reports on the goals in members’ plans and matching them against potential 1915(i) services, the team can quickly find people who would benefit, educate them, and help get those services started. Jodi Nehring is one of those members. She’s been working with her care manager, Rosa Bryant Pulley, for years, and today she’s a barista at 321 Coffee in Raleigh, designing little shapes like anchors in the foam of her lattes. “Jodi has blossomed beautifully,” Rosa says. “She stays on task with her goals, takes suggestions, and executes them with guidance and support from her team.”
2025 Resource and Referral Snapshot, Tracked in MediSked
In 2025, Monarch’s TCM team used MediSked to identify and address health-related resource needs across its panel:
Behind every number is a member like Stacey Price, who first connected with Monarch during a stay at a Wake County non-medical detox and emergency shelter. His care manager, Rosa Pulley Bryant, was a major proponent of helping him get a vehicle, and on New Year’s Eve he became the owner of a Scion through Wheels 4 Hope. Two years sober, Stacey has rebuilt his relationship with his children. “I’ve learned the difference between being bored and being at peace,” he says.
Smoother Audits and Oversight
In TCM monitoring results from various MCO/Tailored Plan partners, Monarch has gotten positive feedback on the team’s best-effort attempts to meet TCM requirements within the timelines stated in the Provider Manual. The easy-to-read documentation in MediSked has become a real highlight of the auditing process. Monarch has also been able to reduce HEDIS gaps in care by using MediSked’s reporting.
Faster, More Accurate Reporting to the State and Tailored Plans
Reporting in MediSked has made monitoring and audit responses smooth, no matter who’s asking. Reports come out quickly and accurately, often within minutes, and one-off requests from the state are turned around quickly with help from the CaseWorthy team. Two reports in particular drive operational decisions for Monarch’s TCM service line:
- The Beneficiary Assignment File (BAF)
- Engagement and caseload tracking
Together they give leadership a clear picture of team performance and panel assignment, which helps Monarch spot trends, decide where to cap caseload capacity, and plan where to grow the team.
Member Engagement through the Portal
For members who use MediSked’s member portal, it’s a one-stop shop to handle signatures for the Care Plan/ISP, which makes the planning process much more efficient. Qualified Professionals from provider agencies can log in, review the plan, sign, and see exactly where short-term goals sit. Members and families can review, approve, or ask for additions in real time, which often eliminates the 45- to 60-minute drive a care manager might otherwise make just to collect a wet signature.
A Better Experience for Care Managers and Families
Supervisors say MediSked’s note and plan auditing processes help keep documentation accurate, which means fewer claims denials and service denials that require MCO/Tailored Plan submission, like 1915(i). Care managers and extenders rely on their daily agenda in MediSked to keep track of upcoming appointments and the many dates and rules that come with TCM requirements.
Families have noticed, too. Amy Callahan spent years being misread by the systems she turned to for help, with a neurological condition that caused tremors leading providers to label her an alcoholic instead of treating her PTSD and Panic Disorder. After connecting with Monarch, she got an accurate diagnosis from medical director Dr. Robert McHale and began working with care manager Andrea Merriman, who took a whole-family approach and brought Amy’s mother Brenda into the process. Today Amy is stably housed in Salisbury, no longer relies on alcohol or drugs, and sews coats for people experiencing homelessness. “Things have changed substantially for Amy,” her mother Brenda says, “and 90% of that is due to support from Monarch.”
Looking Ahead
Monarch is in the process of implementing CORE, the data layer of CaseWorthy’s Whole Person Care platform. The team is especially looking forward to what comes next:
The Monarch team is also watching CaseWorthy’s AI roadmap closely, with particular interest in more effective documentation, better preparation for upcoming visits, and the ability to pick up on trends earlier.
Featuring Insights From:
Anna Marshall is vice president of care management, intellectual and developmental disabilities (I/DD) and Tailored Plan at Monarch. She has more than 30 years of experience supporting individuals, families and organizations connected to mental health, substance use disorders, I/DD and traumatic brain injury services.
Her background includes developing utilization management processes, designing care coordination models for people with I/DD in waiver settings and working with community partners, Consumer and Family Advisory Committees and county officials to address barriers in the behavioral health system and social determinants of health.
Anna has more than 25 years of experience as a certified trainer and mentor trainer in person-centered thinking and planning through The Learning Community for Person Centered Practices. She is also a certified change practitioner through Prosci.
Leigh Herring Daughtridge is a licensed clinical social worker and vice president of care management, behavioral health at Monarch. She has been with Monarch since 2013, beginning as an outpatient therapist before serving as practice administrator for the Nash and Wilson behavioral health outpatient clinics and care management director overseeing teams in Wake and Forsyth counties.
Leigh has experience in behavioral health care settings, including outpatient clinics, inpatient facilities and community-based programs. She earned her bachelor’s degree in social work from East Carolina University in 2004 and her master’s degree in social work from East Carolina University in 2006.
In her current role, Leigh oversees Monarch’s behavioral health care management program statewide. She is passionate about team building, collaboration and helping the people we support reach their goals through whole-person care. Leigh lives in Nashville, North Carolina, with her husband, two children and two dogs.
