Best Practice

Pathways Community HUB

State/Jurisdiction: Ohio
Setting: Community
Population: Life Course Medical & Public Health Professionals
Topic Area: Safe and Connected Communities Care Coordination Healthcare Financing & Insurance
NPMs: NPM 6: Developmental Screening

The purpose of the Pathways Community HUB (HUB) is to provide an evidence-based, organized, pay-for-outcomes focused, network of community-based organizations that hire and train community health workers (CHWs) to reach out to those at greatest risk, identify their risk factors and assure that they connect to medical, social, and behavioral health services to reduce their risk. A certified HUB improves health, reduces costs, and promotes equity. This approach encompasses community network development guidance, incentives for community-based organization collaboration, client and family risk assessments, CHW training, Pathways risk-mitigation workflows to confirm that outcomes are achieved, as well as billing and common reporting and benchmarks. When combined, these tools help communities in their initiatives to improve health equity and measure success of those initiatives. With published evidence of both outcome improvement and cost savings, the Pathways Community HUB approach and its national certification is officially recognized by both payers and policy makers focused on pay for outcomes. The PCHI team assists communities to develop systems to address individually modifiable risk factors (spanning medical, social, and behavioral, and oral health), to effectively identify and address needs by capitalizing on the strong, trusting relationships CHWs develop over time with the individuals and families they serve. Many individually modifiable risk factors hinge on changes in client behavior related to things like nutrition, education, parenting, or compliance with medical care. CHWs, who regularly visit clients in their homes, are in a unique role to be able to support coordination of care, as well as coach and support individuals to learn new skills, get access to needed services, and make vital behavioral changes to improve their health and social outcomes. The Pathways methodology used by the CHWs adds an accountable mechanism to be able to identify and track risk mitigation for evaluation and payment purposes.

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