Connecting those at risk to Care
Community Health Access Project (CHAP)
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 neighborhoods and rural house trailers to engage those populations most at risk. Using specific checklists they identify risk factors. Working as a team with nurses, social workers and in some cases 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.
Some risk factors are not able to be addressed. Following a careful screening many risk factors can be addressed, reducing risk and improving outcomes.
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 Pathways Community HUB Certification Initiative supported by the Kresge Foundation.
We are excited to see many of our clients work forward from high risk pregnancy and homelessness to a healthy baby, stable housing and sustainable employment. 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 goal is risk reduction. As each specific risk factor is addressed (Pathway completed) their risk and risk score decreases leading to outcome improvement and cost savings. Public health, grant makers, Medicaid Managed Care, Community Mill levies and many other funding streams are currently utilized to support this work in locations across the United States.
Example Client Served
Amber is a 17 year old pregnant mother who lives with her 15 month old child in a dangerous housing complex in urban Ohio. She is eligible but has not signed up for insurance. She has no transportation. The eviction notice on the card table creates a different set of priorities that she and her 15 month old have to face. She needs to be found by a care coordinator, who is effective, engaged and supportive in ensuring that she reaches preventive medical care as well as suitable housing, gets back to her GED and eventually employment. The resources available to Amber involve multiple agencies, and tracking that coordination of care across these agencies requires multiple metrics that cross multiple sectors.
A trained and supervised CHW with experience and knowledge related to community resources can work as a team with social workers, and medical personnel. Specific addressable risk factors can be identified and interventions delivered, mitigating and reducing risk over time. The intersection of health, behavioral health and social issues are one set of problems and priorities for our most at risk individuals. Recognizing the critical value of comprehensively addressing these issues with patient centered involvement in the priorities and plan of care is critical for risk reduction, 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. 5% of the population represents 50% of the cost and the greatest weight of our health care disparity. This would be a good place to start. ———————————————–
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.