Franklin County Pathways

Community HUBAligning performance for results-based health

and social servicesQuarterly Learning Session – April 8, 2016

2

Session Objectives

Learning Session Objectives

WHYWhy do we need a Pathways Community HUB

in central Ohio?

WHAT What future value can it add?

HOWHow does a Pathways Community HUB

operate?

Why do we need a Pathways Community

HUB in central Ohio?

3

People in need face

complex and

interconnected

issues, often

requiring them to

seek help from

multiple sources

Health and social

service providers

recognize clients’

multiple needs and

often coordinate

referrals, but varying

approaches and

limited resources

affect results

Funders/payers

question whether

their dollars are

achieving the results

they seek or if

they’re paying for

something that

could have been

prevented

Our community

continues to have 1

in 5 people living

poverty, and 1 in 3

struggling to meet

basic needs

4

Why do we need a Pathways Community

HUB in central Ohio?

What future value can this model add?

5

What future value can this model add?

6

FIND PROVIDE MEASURE

How does a Pathways Community HUB

operate?

7

HUB

• Administrative and information

technology infrastructure that

provides tools, standards, and

resources to operate model

• Provide data processing,

reporting, invoicing, and

collection tools

• Provide or arrange training for

community care coordinators

in Pathways Method and use

of Hub data system

• Support and assist care

coordination agencies in

quality improvement and

quality assurance activities

• Maintain all client data in

compliance with applicable

requirements of HIPAA,

HITECH, and other

regulations

Care Coordination Agencies (CCAs)

• Establish contract and

business associate agreement

with HUB

• Provide care coordination

services to clients using

community care coordinators

trained and supervised in

Pathways Method

• Perform mutually agreed upon

supervision, quality

improvement, and quality

assurance activities

• Ensure sufficient education

and training to community

care coordinators on HUB’s

data system, Pathways

Method, and community

resources

Community Care Coordinators (CCCs)

• Individuals trained, supported,

and responsible for delivering

care coordination services

• Employed by community

based agencies contracting

with HUB

• Work with client on care

coordination plan and monitor

progress to goals and

priorities using Pathways

method

• Provide client referrals and

resources to additional

services

• Maintain proper

documentation of services

provided and progress made

in implementation of care

coordination plan

Funders/Payers

• Public-private entities

establish contracts/

agreements with HUB to

support delivery of care

coordination services to

specific populations using

accountable payment

arrangements

• Contract terms structured

based on payments to care

coordination agencies for

qualifying activities and

outcomes

• Payments will directly support

care coordination activities

and be reinvested in support

of HUB operations

Patient with Diabetes

Increased patient show rates for appointments

Increase in Clinical Outcomes Measures

3/2015 A1C -8.1 6/15 A1C – 7.1 7/2015 A1C - 6

Reduction of barriers for social determinants of health to care for patients

Increased patient compliance in the management of their condition

9lb weight loss Medication

Adherence Better Nutrition

Increased access to resources for patients

How it works

FIND: Initial Checklist – Captures

Comprehensive Risk IssuesPROVIDE: Pathways identified and

initiated

MEASURE: Risk Factor Reduction

Care Coordinator

• 52 yr old, AA female• Medicaid• Food Svc. Employee• Diabetic: A1C-8.1

Risk Assessment Needs

• Eye Exam• Foot Exam• Depression• Furniture (was homeless)• Food Access/Nutrition

Education• Medication Education• Insurance Education

Medical Referral

Social Service

Education

Medical Referral

Social Service

Medical Referral

Eye Appointment

Podiatry Appointment

Nutrition –Fruits and Vegetables

Mental Health Appt.

Diabetes Education –Medication Adherence

Food Pantry

Furniture Bank

Education

Care Coordinator

Using Data

to Improve

Results and

Reduce

Duplication

13

What are your questions?

14