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