Community Health Access Project (CHAP) – Connecting those at risk to Care

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CHAP supports the work of Community Health Workers in Richland County Ohio and operates the local Pathways Community HUB.

CHAP has helped to develop the Community HUB Pathways Model.  The HUB Model is an evidence based community care coordination approach focused on reaching those at greatest risk, comprehensively evaluating their risk factors and accountably reducing them.

The work is done by culturally connected community health workers (CHWs), nurses and social workers. They reach out to engage those populations most at risk.  Using specific checklists they identify risk factors.  Working as a team with nurses, social workers and in physicians they assure that identified risk factors are addressed with specific Pathways that require confirmed evidence based and best practice intervention.

Their work and the Pathways that document the outcome focused steps, assure individuals connect to primary care and prevention services, behavioral health, housing, food, clothing, adult education and employment. Consistent with National Quality Forum (NQF) guidelines of care coordination, each at risk individual receives a comprehensive assessment.  All identified issues within that assessment are prioritized and worked though making sure they connect to the interventions needed. Connection to the interventions that address the identified risk factors confirms that each health, social and behavioral health factor has been addressed and results in reduced risk, reduced stress, improved outcomes and reduced cost.

The Medical Home Pathway is complete when the client has been confirmed to attend their first medical home physician visit.  The Housing Pathway is complete when the homeless individual is confirmed to reside in safe housing. The same confirmation is achieved and documented with the more than 20 Pathways available through the Rockville Institute Pathways Community HUB Certification Program – https://pchcp.rockvilleinstitute.org/

Many of our clients work forward from high risk pregnancy and homelessness to a healthy baby, stable housing and sustainable employment, improved management of chronic disease and many others. The Pathways Community HUB Model is now utilized from infancy to adulthood to assure accountable outreach to at risk individuals, documenting reduced risk, improved outcomes and reduced cost.

 Our latest publication documents a more than 60% reduction in low birth weight and greater than 500% return on investment   (http://link.springer.com/article/10.1007/s10995-014-1554-4). Low birth weight is closely tied to infant mortality. Infant Mortality reduction is a specific focus for future research.

Contractual payment in the HUB model is tied to the completion of the Pathways in a pay for performance approach.  The model is a pay for performance risk reduction approach.  As each specific risk factor is addressed (Pathway completed) their risk and risk score decreases leading to outcome improvement and cost savings.

The national health care system can transform by moving from fragmented silos to a collaborative and accountable approach of identifying and addressing comprehensive risk factors.  ———————————————–

The Pathways Community HUB Model supports the development of community based networks of agencies that are providing Pathway based outreach and care coordination. More information about the efficiency, nonduplication of service and effectiveness of the HUB model is available at http://www.innovations.ahrq.gov/guide/QuickstartGuide/CommHub_QuickStart.pdf

Technical support for building your Pathways program and Community HUB is available at Care Coordination Systems – http://carecoordinationsystems.com/   CCS has developed Pathways Mobile technology supporting CHWs with mobile Pathway/risk reduction tracking and patient education tools.

The National Community HUB Certification has been developed through partnering agencies that include the Georgia Health Policy Center, CHAP, Communities Joined in action and the Rockville Institute.  National Pathways Community HUB Certification is critical to achieving positive outcomes using this model.  Certification and related technical assistance is now available through the National Pathways Community HUB Certification Program at the Rockville Institute in Baltimore Maryland.  More information is available at – https://pchcp.rockvilleinstitute.org/