Pathways Community HUB in Summit County, Ohio
The Summit County Pathways Community HUB is based on the evidence-based model developed by Drs. Sarah and Mark Redding in Mansfield, Ohio. The Pathways HUB represents a network of care coordination agencies focused on coordinating healthcare and social services for pregnant women at greatest risk for experiencing poor birth outcomes. The model utilizes community health workers (CHW's) to identify at-risk individuals, determine their needs and connect them to services through the appropriate standardized "Pathways."
The most important functions of the Pathways community HUB are to: Centrally track the progress of Individual/family clients (to avoid duplication of services and identify and address barriers and problems on a real-time basis); Monitor the performance of Individual/family workers (to support appropriate incentive payments); Improve the health of underserved and vulnerable populations; and Evaluate overall organizational performance (to support appropriate payments, promote ongoing quality improvement, and help in securing additional funding) Women enrolled in other programs based onthe Pathways community HUBmodel have been shown tohavesignificantly lower adjusted odds of experiencing a low-birth weight delivery thanwomen not enrolled in such a program.
Failing Forward Moments
The fail forward was that both grant funded programs had specific requirements that added complexity to the implementation of pathways. Although there were similarities in the types of information collected, there were distinct differences in the process for data collection and the expectations of the home visits. The staff that were trained continued to work as they have been, seeing families and providing education per their grant deliverables. During the first few weeks, there were several times that the staff met with Pathways staff to enter the information into the Pathways software. It became very apparent the transition to the new system was not a simple one. For the one program, staff were trying to retrofit the information they collected from one program and enter into the other. Moreover, they were now doing double-data entry when they were promised a "more efficient system." Secondly, the community health workers from the other agency continued to operate on paper and only collected the information that was required by the grant. They were feeling the burden of the additional paperwork and new processes. Thirdly, the consenting process became overwhelming because each organization had a consent form to participate in the program, to share information and for HIPPA. Then, the Pathways HUB was asking for an additional consent form. The staff was feeling overwhelmed and burnt out by the amount of paperwork that had to be completed.
Key Lessons Learned
We learned the importance of understanding the grant requirements and processes for these programs. It was not enough to review the information that was collected because the process of the data collection impacted their practice. When the HUB launch and there were new forms to be completed, the process to complete these forms had not been developed or implemented. This much change was difficult for staff to adopt. Another lesson was the importance of sharing the consent form with senior leadership at each organization so that the form could be modified, merged or vetted by legal staff before going live. The consent form review has become part of the discussions with senior leadership during the initial contract discussions. A third lesson was that it is difficult to implement a new model, let alone couple it with grant deliverables and a new software system. In retrospect, we thought that utilizing existing programs that served the target population would be more efficient, however, this approach created more challenges. After many trainings, technical assistance sessions, conversations with state grant funders, the HUB in Summit County tabled the merging of these programs in the HUB. While the programs collaborate informally via meetings, quality improvement efforts and referral sharing, these initial launch agencies have not implemented Pathways community HUB model. Rather, they have continued to serve their families using the tools and documents developed by their grant programs. The lesson learned was that it is an easier process to start with staff and organizations that can fully implement Pathways without the constraints of grant funded deliverables
Specific costs include staff, community health workers, the software system, training, and certification fees.
Key Steps for Implementation
Step 1: Convene key stakeholders and introduce the Pathways community HUB model and concepts.
Step 2: Use local community data to identify areas of need, key health outcomes, and priority populations that the HUB will address.
Step 3: Research, learn and understand HUB certification standards (https://pchcp.rockvilleinstitute.org/).
Step 4: Identify the lead agency that will act as the"HUB" agency (the administrative body for the Pathways community HUB). This should be a neutral entity that does not provide services. There should only one HUB per geographic region.
Step 5: Discuss sustainability issues and develop a plan to secure and maintain funding. This may include Medicaid reimbursement mechanisms, local, and/or state funding.
Step 6: Determine key area(s) of focus for the HUB and the key pathways that will need to be utilized during the initial implementation phase.
Step 7: Identify Evidence-based and best practice interventions available in your community to address the identified risk factor(s).
Step 8: Develop systems to track and evaluate performance or invest in current systems that are available (Care Coordination Systems- CCS).
Step 9: Establish contracts with Care Coordinating Agencies (CCA's) who will provide services through the HUB.
Step 10: Create supporting tools and documents for community Care Coordinators (CCC's).
- HIPPA guidance
- Training tools
- System training tools
- Launch guide
- Training curriculum
- Quality Improvement Plan / tools / process
- Operations manual / policies and procedures
- Forms (consent, intake, enrollment, pathways checklists)
Step 11: Determine staffing needs, and hire appropriate staff. (Administrative staff and CCC's)
Step 12: Train and organize CCC's and other staff at participating agencies.
Step 13: Launch the HUB
Step 14: Develop a communications plan to market the availability of the Hub and educate the community about the model.
Step 15: Establish a HUB community Advisory Board.
Community partnerships are a critical component of the Pathways HUB model. A variety of care coordinating agencies are needed to establish a robust referral network capable of addressing all identified social and clinical needs. These may include healthcare providers, social service agencies, and community-based organizations. Additionally, buy-in from local policymakers and politicians, charitable organizations, payers, and private businesses may provide additional necessary support for the program. Summit County Public Health has been an integral strategic partner in this initiative. SCPH has served as the convener in the county for a variety of public health issues, including infant mortality. They are the leaders in data collection, analysis, and dissemination. SCPH facilitates the community health needs assessment and community health improvement plan.
Policies, Laws and Regulations
The Ohio Administrative Code outlines the Ohio Board of Nursing's process for issuing community health worker certifications. The Rockville Institute administers a national certification processfor Pathways community HUB programs. The Ohio Administrative Code outlines the process and requirements for becoming a Medicaid "delegated entity." "Delegated entities" are subcontractors that have been provided the authority by the managed care plan (MCP) to conduct functions and/or services such as care coordination, claims processing, etc.
Required Staffing (FTEs)
4-5 FTEs are required to staff the lead administrative HUBagency. Each contractedCare Coordinating Agency employsat least 0.5 FTEs (case load is approximately 25 cases per 0.5 FTE).
Local foundations. Local, State, and Federal agencies. Third-party payers, such as Medicaid managed care organizations (through contracts with the HUB for services provided). Grant funding to finance the initial planning or startup of the venture.
The HUB should be housed in a neutral entity in the community with strong financial infrastructure and community partnerships. In Summit County, the HUB is housed at Akron Summit community Action, Inc. (ASCA), a private non-profit dedicated to addressing the needs of low-income residents. ASCA acts as the administrator of a variety of programs addressing the social determinants of health, including Head Start, Energy Assistance, the Foster Grandparent Program, Circles, Earned Income Tax Credit and Neighborhood Development.
A centralized, web-based software system (Care Coordination Systems) is being used to ensure standardization of assessments, referrals, and client records. A single software system for all care coordinating agencies allows the HUB to reduce duplication of services, identify gaps in services, track outcomes, and measure the effectiveness of the program. It also provides security for protected health information and allows the HUB to bill insurance companies and Medicaid for services.
Community Care Coordinators must go through the state of Ohio's certification process for Community Health Workers. Additionally, the CCC's must attend a training on the Pathways Hub model and a training on the Care Coordination Systems software system.
Administrative HUB Staff include:
- HUB Director
- Clinical Coordinator
- Quality Assurance Manager
- Referral Coordinator
- Floating Community Health Worker
Care Coordination Agencies:
- Supervisor of community Care Coordinators
- Community Care Coordinators (certified community Health Workers)
Return on Investment Details
This model shows modest return on investment based on previous research. Reduction in preterm births and low birth weight deliveries can significantly reduce short term and long term costs related to NICU medical care, early intervention services, special education services, and lifetime medical costs. The actual return on investment in Summit County is yet to be determined.
- # Preterm births
- # Infant deaths
- # Low birth weight babies born
- Infant mortality rate
- # Care Coordination Agencies
- # Trained CHWs utilizing the software system
- # Referrals
- # Fully enrolled women
- # Babies born
- # Certification standards met
- # Pathways initiated
- # Pathways closed successfully
- # Pathways closed unsuccessfully
- Pathways community Hub Certification Standards (Rockville Institute)
- Connecting Those at Risk to Care: The Quick Start Guide to Developing community Care Coordination Pathways (AHRQ)
- Pathways community HUB Manual (AHRQ)
Family and social support
Access to care
Women's health and wellbeing
Child health and wellbeing
People (community residents, community members with lived experience)
Healthcare, public health department or health services