Pathways Community HUB
CDHD SHIP Team
Central Health Collaborative December 5, 2017
Goals/Objectives
Together we will:
Continue to develop a shared understanding of the Pathways
Community HUB Model
Identify/brainstorm recommendations for next steps
What is a HUB?
Central management organization that guarantees connection to services
Contracts with local organizations to manage and deploy CHWs
Assigns referrals to CHWs to connect individuals to services
HUB
Health Care
Services
Social & Human Services
Payers Schools
Clients
HUB Process
• Identify individuals at greatest risk and provide assessment of health, social and behavioral health risk factors
Find
• Ensure that each identified risk factor is assigned to a Pathway to make sure the risk factor is addressed
Track
• Completion of each Pathway confirms that the risk factor has been addressed. Measurement may include connection to employment, insurance, food stamps, diabetes education or the birth of healthy baby
Measure
Pathways Story – Family at Risk
Leah (Mom) – 22 years old
• Pregnant
• Inadequate housing
• No health insurance
• No prenatal care
• At risk for depression
Marcus (Son) – 6 years old
• Needs a medical home
• 2 ED visits last month
• No asthma action plan
• Not current on immunizations
• Struggling at school
How does this family get connected to a HUB?
Engage Family with Checklists
Use checklist answers to identify Pathways
Connect to Community Care & Support
Example: Leah’s Pregnancy Pathway
•Initiation step – defined ‘at-risk’ pregnant woman engaged and enrolled in care coordination
Initiation – Identify/enroll
at-risk population
•Determine and document barriers
•Insurance Status
•Housing
•Importance of prenatal care
Care Coordination
•Prenatal care provider established
•First and ongoing visits confirmed Evidence-based intervention
•Completion
•Healthy baby > 5lbs 8oz. Completion – final outcome
Track and Measure Progress
One CHW for the Entire Family
Leah (Mom)
• Pregnancy PW
• Employment PW
• Housing PW
• Social Service Referral PW
• Education PW – prenatal, parenting
Marcus (Son)
• Medical Home PW
• Medication Assessment PW
• Tool-Asthma Action Plan
• Education Support
Core Pathways
Adult Education Behavioral Health
Employment Developmental Screening
Health Insurance Developmental Referral
Housing Education
Medical Home Family Planning
Medical Referral Immunization Screening
Medication Assessment Immunization Referral
Medication Management Lead Screening
Smoking Cessation Pregnancy
Social Service Referral Postpartum
Ohio – Standard Billing Codes
Ohio – Who is paying for Pathways?
Community Health Access Project (CHAP) – Mansfield, OH
United Way
Private Donations
United Healthcare
Buckeye Health Plan
Ohio Department of Health
Richland County Foundation
Ohio Commission on Minority Health
National Data
Community Health Access Project (CHAP) – Mansfield, OH
Low birth weight babies
Number of at-risk pregnant women served increased from 19 to 146
in 1 year
Low birth weight rate went from 23% to less than 5%
Michigan Pathways to Better Health – Ingham, Muskegon, Saginaw
Two or more chronic conditions, high social service needs
2,500 linked to a primary care provider
Reduction of 153 transports to ED among 70-80 frequent users
1,700 linked to food services/1,600 linked to transportation
Care Coordination Systems (CCS)
Founded to support the national certification initiative
Guidance towards HUB certification
Provides:
Training
Pathways mobile and HIPAA software
Integrated patient portal
Customizable systems
HUB operations assistance
Risk scoring and stratification
Potential Funding Streams
Braided Funding – Multiple revenue sources
Local foundations
Local, State and Federal agencies
Third-party payers – Medicaid Shared Savings
Examples:
Robert Wood Johnson Foundation
Blue Cross
United Way
CDC, HRSA, CMMI, AAP
Next Steps