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CHW
Leading the Way in Delivering Better Community Health
Pathways and the HUB
Recognition for the Pathways Community HUB
The CMS Innovation Center
@ Care Coordination Systems 2012-2018
Pathways…
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Pathways Care coordination facilitation tools Patient-centered Identify patient risks Social and traditional health issues identified Actionable & accountable Measured outcomes Trained & quality assurance to achieve results Payments for measured Pathway outcomes
@ Care Coordination Systems 2018
Pathways…
@ Care Coordination Systems 2012-2018
Evidence‐based and published model
Identify and reduce social risks to health
Produce measurable outcomes for quality improvement and research
Provide for continuity of care at lower cost
Improve quality of care
Lower cost of care through risk reduction
Provide Community‐Based Intensive Care Coordination for High Risk Members
Reduce isolation
Increase patient engagement through coordinated community‐based care
Identify and Reduce Hospital Readmission
Identify and Reduce unnecessary ER/ED utilization
Reduce Skilled Nursing Facility Usage
Reduce health disparity & inequities
Reduce low weight birth rates and pre‐term births
Reduce infant mortality
Applicable to Chronic Conditions Applicable to Maternal Health Applicable to Behavioral Health Applicable to Seniors and Pediatrics Applicable to Opioid Use Disorder Applicable to Substance Use Disorder
Additional Pathways Uses
@ Care Coordination Systems 2012-2018
Document for Transitional Care Management Revenue
Document for Chronic Care Management Revenue
Integrated with multi‐model Community Health Record platform
Connected with EHRs and Health Information Exchanges
Cited as suggested model for CMS Innovation grants
Measured outcomes produce invoicing transactions for sustainability
Recognized for innovation and results by leading healthcare organizations
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Reducing Risk for Communities
@ Care Coordination Systems 2018
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Social Influencers of Health
Clinical Measures
Social Influencers of
HealthOccupation
Education
Culture
Socioeconomic Status/Income
Neighborhood Race/Ethnicity
@ Care Coordination Systems 2018
“Typical” Family at Risk
Marisol, 21
Angelina, 16 months
Mrs. Garcia, 52
• Needs medical home• Behind on imms.• Behind on well visits• Developmental
concerns ?
• Pregnant• Lost job• No housing• No transportation• Depressed ?
• Diabetic• Lives in 1
bedroom apt.• Limited income,
works 32 hours• Financial
stressors ?
@ Care Coordination Systems 2018
Current Community Care Coordination
HHS MEDICAID MANAGEDCARE
EARLY CHILDHOOD
CHILD PROTECTIVE SERVICES
HEALTH PLAN
Marisol Angelina Mrs. Garcia
Multiple care coordinators involved –limited communication
@ Care Coordination Systems 2018
PREGNANT CLIENT
Click to edit Master text styles•Second level
• Third level• Fourth level
• Fifth level
Regional Organization and Tracking of Care Coordination
AGENCY AGENCY AGENCY AGENCY
CARE COORDINATION AGENCIES
COMMUNITY HUB
• Demographic Intake• Initial Checklist -- assign Pathways• Regular home visits – Checklists and Pathways
completed• Discharge when Pathways completed (no issues)
CLIENT
CARE COORDINATOR
@ Care Coordination Systems 2018
Marisol
Angelina
Mrs. Garcia
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• Medical Home PW• Immunization
Referral PW• Medical Referral PW• Developmental
Screening PW
• Pregnancy PW• Employment PW• Housing PW• Medical Referral
PW• Social Service
Referral PW• Education PW –
prenatal, parenting
• Medical Referral PW –primary & specialty
• Housing PW• Social Service
Referral PW• Education PW -
diabetes
@ Care Coordination Systems 2018
HUB
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HHSHousingAAA
Medicare/MedicaidManaged Care
State AgenciesCounty Departments
Private Health PlansFoundations
ClinicsFQHCsHospitalsPhysicians
One Care Coordinator for the Entire Family
@ Care Coordination Systems 2018
“Care Traffic Control”
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Engagement of at risk client Collect information – Initial Checklist
Assign Pathways Track/Measure Results (Connections to Care)By: Care Coordinator, Agency, Region
Find. Treat. Measure.
Step 1: Find Step 2: Treat Step 3: Measure
@ Care Coordination Systems 2018
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Find
Do you need a primary medical provider?
Do you need health Insurance?
Do you use tobacco products?
Do you need food or clothing?
Step 1: Engage at-risk clients with checklists.
Example Checklists
• Initial Adult
• Adult
• Initial Pregnancy
• Pregnancy
• Initial Pediatric
• Pediatric
Use checklist answers to identify Pathways to follow
@ Care Coordination Systems 2018
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Treat - Pathways
@ Care Coordination Systems 2018
Measure
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Step 3: Track and Measure Progress
Name Medical Home
Pregnancy Social Service
CHW A 5 2 10
CHW B 1 3 4
CHW C 9 15 18
Site MedicalHome
Pregnancy SocialService
Agency A 50 25 22
Agency B 64 17 35
Agency C 40 32 19
By Community Care Coordinator
By Agency
Example Tracking Filters
• Care Coordinator
• Agency
• HUB
• Community
• Region
• Etc…
@ Care Coordination Systems 2018
Dramatic Pathways Results
6.1
13.0
0
2
4
6
8
10
12
14
16
18
% of Low
Birth Weigh
t Births
Pathways Intervention
Achieved through focus on social risk factors and organized care coordination in Pathways Community HUB
ControlGroup
Maternal and Child Health Journal
Maternal and Child Health JournalISSN 1092-7875Matern Child Health JDOI 10.1007/s10995-014-1554-4
Leading the Way in Delivering Better Community Heath
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20 Core Pathways
• Adult Education• Employment• Health Insurance• Housing• Medical Home• Medical Referral• Medication Assessment• Medication Management• Smoking Cessation• Social Service Referral
• Behavioral Referral• Developmental Screening• Developmental Referral• Education• Family Planning• Immunization Screening• Immunization Referral• Lead Screening• Pregnancy• Postpartum
@ Care Coordination Systems 2012-2018
Distinctions between Pathways & HUB
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Pathways Care coordination facilitation tool Patient-centered Identify patient risks Social and traditional health
issues identified Actionable & accountable Measured outcomes Trained & quality assurance to
achieve results Payments for measured Pathway
outcomes
Community HUB Tracks Pathways (outcomes)
across agencies Eliminate duplication Streamline referrals Provide infrastructure for
community-based care coordination
Involve braided funding –Pathways can be purchased by different funders
Invoicing system
@ Care Coordination Systems 2018
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Standardized Billing CodesNormal
RiskHigh Risk
Modifier
ChecklistsInitial Pregnancy Checklist
Completed one time at Member enrollment, 1st
trimester engagementG9001 G9003 R1
Completed one time at Member enrollment, 2nd
trimester engagementG9001 G9003 R2
Completed one time at Member enrollment, 3rd
trimester engagementG9001 G9003 R3
Pregnancy Checklist
Completed at each face-to-face encounter with Member
G9005 G9010 R
PathwaysBehavioral Health Kept three scheduled behavioral health appointments G9002 G9009 RB
Education Educational module delivered. G9002 G9009 REFamily Planning LARC (long-acting, reversible) or permanent method G9002 G9009 G1
Family Planning All other family planning methods G9002 G9009 G2Housing Residing in affordable & suitable housing for 2
months.G9002 G9009 RI
@ Care Coordination Systems 2012-2018
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National Certification
@ Care Coordination Systems 2012-2018
Pathways Community HUB Model
• Removes “silos” and fragmentation• Uses existing community resources efficiently
and effectively• Focuses on common metrics to identify &
track risks (risk reduction)• Holistic community care coordination – one
care coordinator • Pays for outcomes – sustainable• Owned by the community
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CHRCommunity Health Record
Pathways HUB Connect
Creates Community-Clinical Linkagesthrough Care Coordination
Pathways Mobile
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Real-time Pathways and SDOH information from the community
@ Care Coordination Systems 2018
Pathways HUB Connect
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HUB Connect enables organized and efficient community
care coordination.
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Pathways HUB Connect
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Pathways HUB Connect
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Information and Reporting
@ Care Coordination Systems 2012-2018
Access Real-time Member Information
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Pathways Risk Scorecard Report
With Client, Family and Household Aggregation Options
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Integration with Care Delivery
Referral to HUB form
Care Team Dashboard
Health Information Exchange
Direct Messaging
API library• Bi-directional• Documented
ACH / Pathways
HUB
Community Agency
Community Care
Coordinator
Patient Care Team
ProviderClinic
Care Managers
Completing the Care Team Loop
@ Care Coordination Systems 2012-2018
RiskQ for Hospital Readmission
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Public, Organization and HUB client‐facing site for Community Referrals
HealthBridge.care - Community Resources & Referrals
RiskQ for Hospital Readmission
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HealthBridge.care - Community Resources & Referrals
@ Care Coordination Systems 2018
HealthBridge
Hospitals, Providers &
Organizations
Pathways Community
Hub
Community
Multi-directional referrals and conversationsHospitals, Providers and OrganizationsPatients/Members/Clients/PublicCommunity-based OrganizationsCare Coordination
Integrated with Pathways (evidence-based model)
Secure and HIPAA-compliant
Also with Chronic Care Management and Transitional Care ManagementHealth Engagement TeamHealth Homes
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Referrals – Conversations
@ Care Coordination Systems 2012-2018
Health Bridge
Client / Public
Hospitals, Providers and Organizations
Community-based
Organization
Pathways HUB
Care Coordinator
35@ Care Coordination Systems 2018
HealthBridge Conversation Videos
The first video has John Exampleton, a HUB client, at the public facing website self‐referring with a community‐based organization (CBO). The care coordinator is kept up to date in the Pathways.
https://www.youtube.com/watch?v=AnLStiJryNI
The second video has the care coordinator making the referral to the CBO on behalf of John Exampleton, HUB client. The conversation is tracked in Pathways. John Exampleton has access to the schedule and conversation at the HealthBridge.care site.
https://www.youtube.com/watch?v=Fv3G4nj7ku0
https://www.HealthBridge.care
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Integration with Care Delivery
ACH / Pathways
HUB
Community Agency
Community Care
Coordinator
Patient Care Team
ProviderClinic
Care Managers
Pathways Community HUB
@ Care Coordination Systems 2012-2018
Community Service provider
Hospital/ Organization
Client/ Patient/Provider
HealthBridge.care – Enhancing care with Community Resources and
Partners
Interoperability
Community Resources and Engagement
HB
CHR
Health
Behavioral Health
Social
Patient Activation
Family & Personal Health Management
Financial
Pathways RiskQtm
@ Care Coordination Systems 2012-2018
RiskQ for Hospital Readmission
38@ Care Coordination Systems 2012-2018
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Standard Billing CodesNormal
RiskHigh Risk
Modifier
ChecklistsInitial Pregnancy Checklist
Completed one time at Member enrollment, 1st
trimester engagementG9001 G9003 R1
Completed one time at Member enrollment, 2nd
trimester engagementG9001 G9003 R2
Completed one time at Member enrollment, 3rd
trimester engagementG9001 G9003 R3
Pregnancy Checklist
Completed at each face-to-face encounter with Member
G9005 G9010 R
PathwaysBehavioral Health Kept three scheduled behavioral health appointments G9002 G9009 RB
Education Educational module delivered. G9002 G9009 REFamily Planning LARC (long-acting, reversible) or permanent method G9002 G9009 G1
Family Planning All other family planning methods G9002 G9009 G2Housing Residing in affordable & suitable housing for 2
months.G9002 G9009 RI
@ Care Coordination Systems 2012-2018
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CHW
Leading the Way in Delivering Better Community Heath
Care Coordination Systems
Certified Pathways Community HUB
Pathways RiskQ &Pathways Insight Research
Community Health Record Pathways HUB Connect
HealthBridge.care & Pathways Community
Community Health Worker, Supervisory, HUB Staff & Pathways Training
PathwaysChronic Care Management
Transitional Care Management
Health Engagement TeamHealth Homes
The comprehensive solution provider for turn-key Pathways Community HUBs
– Pathways (evidence-based)
– Training– Pathways mobile– HIPAA-compliant, Secure– Integrated community
resources and referral– Integrated population health
education patient portal– Customizable systems– HUB operations advisory– Risk Scoring and stratification– Other proven models on the
same platform
The tools, templates, best practices and processes for Pathways Community HUB certification!
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PREGNANT CLIENT
Leading the Way in Delivering Better Community Health
CCSPathways.com
HealthBridge.care
[email protected] 708-906-3057
41@ Care Coordination Systems 2012-2018
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