Hub / Program Name:

Care Coordination Programs of CHOICE Regional Health Network (CRHN)

Location: Olympia, WA

Dan Rubin of Olympia, Washington.  The program covers the southwest portion of Washington state, a mostly rural area. The program collaborates with the medical community and social services. CHOICE has put together a considerable consortium including hospital, key clinics including the four participating in the state Patient Centered Medical Home collaborative, both Area Agencies on Aging, all three major mental health agencies in our region, and at least two of the three largest physician networks (including the one that focuses on independent small practices).  CHOICE is building in monetary incentives for good care coordination outcomes. 

Hub/Program Website: http://healthreformwa.org

Hub / Program Name:

Central Oklahoma Project Access (COPA) Community Health Worker/Health Care Navigator Program

Location: Oklahoma City, OK

Mary Overall of Oklahoma City is coordinating a community access program and developing a Hub. About 6 local hospitals and 150 physicians are involved in the Central Oklahoma Integrated Network System (COIN). Partners include local social service organizations, the county and state level health departments, all helping build a safety net. Overall’s group is organizing the process. Finding enough funding has been a challenge. The program has 2 workers, who are largely devoting their energy to securing funding. In the early part of 2007, the workers educated 6 community health workers to launch Pathway model. Two of those community health workers are still involved. This year, trained 6 more. COIN is working with federally-qualified health centers. The network plans to focus on cardiovascular and diabetes. One of community health workers has about 36 consistent patients she’s working with.

Best accomplishment: A community health worker is working with a group of people with diabetes and other chronic diseases and using Pathway model. Currently Ms. Overall  in the process of writing a grant to train more CHW's and have partnered with the Metro Technology Program for integration of the curriculum into their system. Further, she is waiting feedback on a grant written to an FQHC for a peer-to-peer support group using CHW's.

Hub / Program Name:

Coalition of Community Health Clinics Access and Referral Program

Location: Portland, OR

Laura Brennan of Portland Oregon shares that Oregon recently passed health care reform legislation that was influenced by the Pathways Hub model. Oregon is creating Coordinated Care Organizations that integrate physical health, mental health, and dental health services to create a single point of accountability for the health of the entire population they serve. Further, CCOs will reimburse for Medicaid services through a global budget designed to cover all types of care. That will allow opportunities for organizations and providers to be paid in a different way and to allocate resources for services that reward value - not volume. The idea is that there will be less pressure for unnecessary services and more ability for providers and health workers to spend time on care that focuses on wellness and prevention. And if a CCO meets performance goals – healthier patients and fewer hospitalizations for instance— there will be opportunities for shared savings among providers, organizations and communities.

Hub / Program Name:

Healthy Moms & Babes

Location: Cincinnati, OH

Judith Warren, MPH, Executive Director of Health Care Access Now (Cincinnati, Ohio), shares her developments of the Pathway  HUB, which consists of multiple community providers: FQHC practice sites, social service and public health agencies and a local hospital. Currently, two Pathway programs target reduction of low birth weight deliveries, increased access to medical homes, and reduction of avoidable ED visits for Ambulatory Sensitive Conditions. HCAN has successfully negotiated outcome-based contracts with Medicaid managed care plans. These contracts have led to additional business opportunities that allow HCAN to expand Pathways and serve additional high risk populations, such as Medicare eligible adults who are likely to experience hospital readmissions.

Hub/Program Website: www.healthcareaccessnow.org;

Hub / Program Name:

Lucas County Initiative to Improve

Birth Outcomes

Location: Toledo, Ohio

Jan Ruma of Toledo, Ohio leads an initiative to improve birth outcomes. The focus of the program began in 2008 focusing on women living in zip codes where low birth weight is more common, predominantly in the inner city; the population is 70 percent African American. The Hub started to enroll women actively in 2008, expecting to enroll approximately 100 women per year which soon turned into 500 women averaging 5 or more risk factors, with a high chance of poor birth outcomes.

Biggest accomplishment: Moving from grant funded care coordination to Medicaid managed care funded care coordination for at-risk women. The Initiative has achieved a low birth weight rate of less than 7% in 2011 compared to almost 20% in some zip codes.

Question: Are care coordinators recording or making history?

Hub/Program Website:

http://hcno.org/health-improvement-initiatives/pathways.asp

Hub / Program Name:

Kansas Health Information Network, KHIN

Location: Kansas City, MO

Laura McCrary Ed.D of Kansas noted that KHIN is a state wide health information exchange serving all health care stakeholders in the state of Kansas.  KHIN connects hospitals, physicians, long term care facilities, safety net clinics, public health departments, labs, pharmacies and other health care stakeholders together to securely share a longitudinal patient health record at the point of care.  Patients also participate in KHIN and access their own longitudinal health information to enable them to better manage their own health care.  As of January 3, 2012 KHIN participants include 39 hospitals, 78 clinics and over 1100 providers that span the entire state of Kansas.   The KHIN technology aggregates data from many different providers into a consolidated dashboard that providers and community care coordinators use to identify patients that may be at risk of compromised health outcomes.   As KHIN builds its technology infrastructure, care coordinators will utilize health data in conjunction with Pathways, incorporated in the health information exchange, focused upon social determinates to improve population health management and the health outcomes for individual patients. 

Hub/Program Website: lmccrary@khinonline.org. 

Hub / Program Name:

Muskegon Community Health Project

Location: Muskegon, MI

Vondie Woodbury of Muskegon, Michigan is he Executive Director of a project that began in 1993 as a partnership between the Community Foundation for Muskegon County and W. K. Kellogg Foundation to better manage local health resources.  A 501 [c] 3 tax-exempt organization since 1999, the Muskegon Community Health Project (MCHP) became affiliated with the Trinity Health System in 2008 and serves as the Community Benefit arm of Mercy Health Partners, the unified health system covering three counties in Western Michigan.  The Health Project convenes and staffs 17 collaborative bodies of community members, which deal with a variety of local health issues, such as substance abuse, tobacco cessation, asthma, pharmacy access, minority health, HIV/AIDS, childhood obesity, end of life, Diabetes, dental care and Hepatitis C.  The Health Project is recognized nationally for its leadership in developing local initiatives that address access to care, health disparities, chronic diseases, health education, prevention and wellness.  MCHP is best known for creating the Access Health “3-Share” national model for community health care coverage program, which celebrated its 10-year anniversary in 2010.  Small businesses can enroll low wage full-time and part-time employees in the program at very affordable costs.  Other states have adopted the idea, as well. 

The Health Project adapted the Pathway model in 2004 to address the chronic health issues of parolees in twelve counties of West Michigan.  In addition to re-entering parolees, the MCHP has many years of experience using the Pathways approach for high-risk adults, including at-risk pregnant women and low-adhering diabetes patients.  MCHP’s Pathways partners include:  Grand Valley State University/Kirkhof College of Nursing, four public school districts, two FQHCs, Public Health, Community Mental Health and behavioral health providers.

Hub/Program Website: http://www.trinity-health.org/

Hub / Program Name:

Pathways of Bernalillo County

Location: Albuquerque, NM

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Daryl Smith and Leah Steimel from Albuquerque, New Mexico.  In 2008, The University of New Mexico Health Sciences Center, Office of Community Affairs (OCA), along with 35 community partners, engaged in a collaborative planning effort to bring a Pathways Program to the greater Albuquerque community.  Through these efforts, the Bernalillo County Commission convinced the University of New Mexico Hospital to commit no less than $800,000 a year for 8 years from the mill levy funds it receives each year from the County.  In spring 2009, the OCA issued a request for proposal (RFP) and awarded $644,000 to 14 community-based organizations to roll out Albuquerque’s version of the Pathways model.  The initial RFP was for a 2-year duration, planned as the demonstration phase for a minimum 8-year Pathways Program.  Across these 14 organizations, more than twenty (20) community health workers (Navigators) were trained on the model.

Overall, the Pathways to a Healthy Bernalillo County 2-year pilot phase was successful and effective in fine-tuning data collection instruments and the program database design;  gaining a better understanding the target population;  building communication and networks among health and social service agencies;  and beginning to recognize the necessary steps needed for improved health systems.  While performance varied from organization to organization, overall, nearly five hundred (490) unduplicated individuals participated and completed their involvement in the Pathways Program over the first two years.  Greater than one thousand two hundred fifty (>1,250) separate pathways were completed during this period, indicating that the individuals achieved the final step (healthy outcome) in a particular pathway. 

Six-month post-Pathways follow up surveys with a sample of these clients have been conducted by the Evaluation Team to assess the impact that the Pathways Program had on their lives.  Over 90% of participants interviewed felt that the program was having an impact in the community beyond what it had done for their own individual situation, and most gave examples of how they had personally helped others by sharing information they had gained from participating in Pathways.  Participants said that they had a better understanding of how to utilize health and social services systems (72%) and that they are now able to advocate for themselves in matters related to health and social services (65%).  

In January 2011 a second RFP was issued by the OCA, which incorporated many of the recommendations for improvement made by the Navigators during the standing monthly meetings held over the first 2 years.  A total of thirteen (13) organizations were funded in this second round.  Regrettably, four of the original partners were not

re-funded, however, five new partners were awarded funding for this current 4-year cycle thus further expanding the network.  The amount of funding appropriated in contracts for this current cycle has risen slightly to $660,000 per year.   

Hub / Program Name:

Pathways to Health Project –

The Health Partners Initiative (HPI)

Location: Lincoln, NE

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Jean Stilwell, Resource Development Director at Saint Elizabeth Foundation , Lincoln, NE and Tom Hoover, RN, is the Program Director.  Lincoln ED Connections is a collaborative program of Bryan LGH Medical Center and Saint Elizabeth Regional Medical Center, providing case management services for patients who utilize the three emergency departments in Lincoln for non-emergent reasons. Patients are enrolled, establish a care plan using the Outcomes Pathway model, and are assisted in overcoming barriers to optimal health outcomes.  According to patients’ needs, they can be assisted with food, utility bills, transportation, medication assistance, and other essential services. All patients are assisted with connection to a medical home and are evaluated for mental health and substance abuse treatment. The Lincoln ED Connections program is described in more detail on the AHRQ Innovations Exchange website and is titled,  Hospital Partnership Offers Pathways-Based Case Management Program, Leading to Enhanced Access to Appropriate Care for Uninsured.

Hub/Program Website: www.saintelizabethonline.com, www.bryanlgh.com

Hub / Program Name:

Project Access Dallas

Location: Dallas, TX

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Jim Walton and Adam Chabira of Baylor Health Care System in Dallas.  Baylor Health Care System has a strong commitment to improve access to care for historically underserved populations in the greater Dallas-Ft. Worth region.  Through its Baylor Community Care (BCC) initiative, Baylor Health Care System has devoted significant resources to operate a network of primary care clinics and other supportive services designed to improve health outcomes for patients while reducing avoidable hospital utilization and costs.

A key component of the Baylor Community Care strategy is the use of Community Health Workers (CHW’s) to provide health education, health system navigation, and patient advocacy.  Known as Community Care Coordination (CCC), these programs have become an integral part of health care delivery within Baylor Community Care.  Over the past three years, Community Care Coordination has experienced tremendous support and growth.  Major accomplishments include:

1. In 2009, Baylor Community Care was successful in securing a five-year $1.6 million grant from the Merck Co. Foundation to expand a successful diabetes education pilot into four new clinics.  Three years later the program has demonstrated successful outcomes for enrolled patients.  994 patients were enrolled in the first 24 months and 276 completed the first year. The majority of patients were female (60%), between 40-59 years of age (64%), and Hispanic (70%). The mean HbA1c value at baseline was 8.5% dropping to 7.2% after 12 months.  Over 99% of participants reported they were very satisfied with the care they received.

2. Baylor Community Care implemented its Community Care Navigation program.  The CCN program deploys CHW’s within Baylor hospitals to identify uninsured patients who require ongoing care following discharge and connect them to medical home clinics in the BCC network.  Today, the Community Care Navigation program is in place at four Baylor campuses.  In 2011, the program successfully connected 806 patients.

3. Baylor solidified its commitment to furthering the profession of Community Health Workers through the creation of formal job classifications for CHW’s within its human resources structure.  Baylor has supported the formal education of these employees, all of whom have completed CHW certification from the State of Texas.  In addition to the ten (10) certified CHW’s employed within Baylor Community Care, several other departments including Social Work and the Diabetes Health & Wellness Institute have employed Community Health Workers.

Hub/Program Website:

http://ardd.sph.umich.edu/baylor_health_care_system.asp

Hub / Program Name:

Rio Arriba County Pathways Pilot Project

Location: Rio Arriba, NM

Lauren Reichelt of Northern New Mexico described challenges in her very rural region, where 41,000 people live in a large, mountainous area. One can’t locate people in need geographically: movie stars live next to people in adobe houses with no running water or electricity. The Pathway started with pregnant, substance-abusing women; the program saw 20 such cases last year. Some had already had children that had been removed by social services. A big accomplishment was that of the 20 women, 15 had babies, 14 with viable birth weights and no substances in their bloodstream. One issue for these women is inadequate access to family planning even though they have had children taken away. Domestic violence is also an issue for them. Ms. Reichelt’s group has also helped provide mental health assessments, largely for released jail inmates, but was not allowed by the state to followup. In this population, out of 166 people for whom did referrals, 80 percent didn’t show up (20 percent success). This is in contrast to the pregnant women who had Pathways care coordination, where the success rate of followup was 95 percent.

For the coming year, funders are supporting the Pathways model. The organization will be continuing its pilot project with pregnant, substance-abusing women and is working with Espanola Hospital to develop an Emergency Room Diversion Project. There has been more support for the program. The state of New Mexico is looking to Rio Arriba County to identify lessons learned as it attempts to help other counties develop ER Diversion Projects. And Health Insight New Mexico, the state QIO, is working with Rio Arriba to develop and innovative health care model for Medicare and Medicaid recipients that can be rolled out statewide. Rio Arriba County has emerged as a leader in New Mexico despite its reputation as a perennial underdog.

Ms. Reichelt noted that after she wrote a letter to Tikkun magazine, she was invited to become their health care blogger.

Hub/Program Website: www.rachc.org.

Hub / Program Name:

Rural and Urban Access to Health (RUAH)

Location: Indianapolis, IN

Sherry Gray and Susie Dittman of St. Vincent Health in Indianapolis. The Rural and Urban Access to Health (RUAH) program began in 2000 as part of an HCAP grant. In 2005, St.Vincent Health took on the program as a permanent department within the organization. RUAH has Health Access Workers (HAWs) and Medication Access Coordinators (MACs) in several rural communities surrounding Indianapolis.

Biggest recent accomplishment RUAH developed five Pathways: Medical Home, Medical Referral, Pregnancy, Enrollment, and Social Service. They deployed them to their web-based data collection system, eCAP, and the Pathways are now used by all of their Health Access Workers. Additionally, they created new reports to reflect the change from an activity-based model to an outcome-based model. Currently, RUAH is working on updating eCAP to accommodate the new format, and they are also exploring adding additional Pathways.

Hub/Program Website: http://www.stvincent.org/Community-Connections/Programs/Advocacy-Support-Programs/Rural-and-Urban-Access-to-Health.aspx