Impact
Sustainability
The PCH Entity is a third party neutral entity that creates structure and governance oversight creating a social managed services organization or backbone organization that partners with CBOs to provide services such as billing, contracting, quality assurance, and data standardization. The PCH Entity also contracts with funders such as health plans, health systems, and government agencies, to structure a pay for outcomes model.
The Care Coordination Agencies (CCAs) hire Community Health Workers (CHWs) to identify high risk or rising risk individuals, screen these individuals for needs, refer, and close pathways. The CHWs work with all family members to ensure care coordination is provided to everyone who needs it addressing any barriers that arise and transforming a community's health. The standardized 21 Pathways provide the ability to identify each patient’s unique risk profile, and create an appropriate care plan that mitigates risk in a cost-efficient, sustainable manner enabling cost savings and quality care.
The PCH model removes the need for CHWs and CCAs to rely on one time grant funding. It removes the CCAs from needing to fundraise and can focus on the work that they do best.
Funders only need to contract with the PCH Entity to engage CHWs and decreasing the need for their own CHW workforce. Funders are only paying for standard outcomes that have been completed, aligning incentives from multiple stakeholders and achieving sustainability.
Addressing Health Equity
Addressing All Needs and providing Greater Access: By screening for all social needs, not just a few, the CHWs are empowered to support a community member’s holistic health and their family members. In this model, a CHW can help connect any community member to services as long as they have social needs that need to be met and are willing to meet them.
Workforce Development for inclusive Language, Culture, and Location: The Pathway Community Hub can contract with multiple Care Coordination Agencies that employ CHWs - these agencies can be large or small. This will ensure smaller entities with specific skilled CHWs, for example those that speak certain languages or come from certain subset of cultures, are able to work with their own vulnerable populations, breaking the cycle of inequities. These Care Coordination Agencies can also deploy their CHWs across a wide range of geographic locations, increasing footprint in areas that might not have an anchor institution present. CHWs are hired locally, in the community, and have similar lived experiences as the individuals they will be serving.
Identifying Gaps in the Community and Addressing the Needs: One of the primary objectives for a Pathway Community Hub is to find individuals who are at-risk or are rising-risk for poor health outcomes and because the work is tracked electronically, success can be measured through the elimination of those risks. The first step is for CHWs to engage with individuals to complete a comprehensive assessment. This assessment looks at all the Pathways that need to be addressed. Then CHWs partner with the individual to work through the identified Pathways. Completed and uncompleted Pathways are recorded and tracked to better understand what is and isn’t working within the community. By measuring incomplete Pathways, the Pathways Community HUB entity can identify gaps in the community’s resources and work with foundations or investors to seek funding to address these gaps. Over time, there will be a decrease in the number of incomplete Pathways due to community capacity.
The Pathways Community Hub is an integrated model that utilizes a localized, outcomes-based approach to connect patients and providers enabling: 1) greater access to services, 2) mitigating risks of community members, 3) standardizing processes and data, 4) while reducing overall health care costs.
Community Health Workers are the Foundation of the Model
A Community Health Worker (CHW) is a frontline public health worker who is a trusted member of and/or has a close understanding of the community served through shared traits.
The Pathways Community HUB (PCH) model is rooted in the belief that a thorough and coordinated care plan created by a trained, local community care coordinator to address an individual’s social determinants of health can mitigate negative social determinants and produce better health outcomes for people at risk.
A Community Health Worker (CHW) is a frontline public health worker who is a trusted member of and/or has a close understanding of the community served through shared traits.
The Pathways Community HUB (PCH) model is rooted in the belief that a thorough and coordinated care plan created by a trained, local community care coordinator to address an individual’s social determinants of health can mitigate negative social determinants and produce better health outcomes for people at risk.
Return on Investment:
$1 returns $5.60
The Northwest Ohio Pathways Community HUB (Centene Ohio Plan), demonstrated that high-risk mothers without HUB intervention were 1.6x more likely to deliver a baby needing special care.
Savings = $5.6 for every $1 spent on HUB.**
Adding CHWs to a medical home in the South Bronx, New York showed: a drop in hospitalizations by 12.6% among patients with diabetes and other chronic conditions while ED visits fell by 5%.
This equated to Savings of $170,213 generated annually by each CHW.*
**Redding, et. al. 2015 NIH: Pathways Community Care Coordination in low birth weight prevention.
*Henry, Tanya. 2020. AMA: How Community Health Workers can help improve outcomes, cut costs.
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