Bridging the gaps between the community and the clinic... Pathways Community HUB
(Photo - Risk Factors Addressed to Achieve Wellness - Pathways Community HUB Institute, all rights reserved)
In June 2018, the North Central Accountable Community of Health’s Governing Board designated Community Choice (dba Action Health Partners) as the lead agency for the Pathways Community HUB. One of the six selected Medicaid Transformation Projects, the Pathways Community HUB is a care coordination model that uses community-based care coordinators (called Pathways Community Specialists) to bridge the connection between clinical and non-clinical support services (such as housing, education, or food.)
“If you sit back and think about the potential of this program, it’s almost unfathomable in what it can do” says Kayelee Miller, Care Coordination Network Director for the Pathways HUB.
The Pathways Community HUB launched on October 1, 2018 with funding from the North Central Accountable Community of Health as a part of the state’s Medicaid Transformation efforts. The HUB is currently serving residents receiving (or currently eligible for) Medicaid benefits in Moses Lake, WA, who have visited the emergency department three or more times in the past 12-months. While the plan is to someday expand regionally, the HUB is starting small on purpose. “Our initial target population is in continuous quality assessment mode. We are fine-tuning our services to make sure we are serving the people who need services the most” says Deb Miller (no relation), Executive Director of Community Choice (the HUB’s lead agency.) 
(Photo - Deb Miller, Executive Director of Community Choice dba Action Health Partners at Pathways Community HUB informational meeting, October 19 - photo by NCACH)
According to a 2014 report released by the National Institute for Healthcare Management, 5% of the U.S. population accounts for 50% of annual healthcare spending the United States. By providing care coordination and access to critical support services such as housing, education, nutrition, or smoking cessation, models like the HUB can help save money in the long-term while working to improve health outcomes at the individual level.“The HUB will help shift our thinking. ‘Health’ doesn’t always mean healthcare” says Deb Miller. “It seeks to bridge the gaps in the system, including the gaps between community-based organizations and medical providers. [The Pathways Community HUB] will help community organizations come together collectively.”
How it works
The Pathways HUB model was originally developed in Columbus, Ohio to address populations experiencing low birthrates by Dr. Sarah Redding. Redding believed that by creating a one-stop care coordination system that would connect clients to critical services while incentivizing outcome targets for care coordinators would create an interconnected system that reduced duplication and eliminate client health risk factors. She was right. A Pathways Community HUB pilot project was launched in Richland County, Ohio in 2005 to provide community-based care coordination services for pregnant women who were at risk of experiencing low-birth rates. As a result, Richland County’s low-birth rates dropped from 9.7% to 8% by 2008. Read more - Redding, Sarah et al. “Pathways community care coordination in low birth weight prevention” Maternal and child health journal vol. 19,3 (2014): 643-50.To date, the HUB model has been implemented in communities across the country as an evidence-based model proven to decrease healthcare spending costs while increasing health outcomes for high-risk individuals.
(Photo - Pathways Community HUB model - Pathways Community HUB Institute, all rights reserved)
It works like this…
Meet Emma and her son Alex.
(Photo - "Emma and Alex" - Pathways Community HUB Training Module - Community Choice dba Action Health Partners, all rights reserved.)
Emma is a single mom and she recently lost her job. Emma is behind on her rent and is likely going to be evicted from her apartment within the next few months. Alex is 2 months old and was born 6 weeks prematurely, so Emma is concerned he may have developmental issues.Emma and Alex are currently receiving support from multiple health care and social service organizations, but Emma struggles to get to their appointments. Emma recently took Alex to the ER for the third time for a high fever and a physician referred her to a program called the Pathways Community HUB.The Pathways Community HUB staff first must confirm that Emma and Alex are eligible for HUB services and that they are not enrolled in another care coordination program. This is done to reduce duplication of services.The HUB then determines which Community Specialist Services Agency (CSSA) would be best suited to work with the client and sends a referral to the supervisor of the agency. Emma and Alex are then assigned a personal care coordinator, called a Pathways Community Specialist, to help coordinate their care. 
(Photo - North Central's Pathways Community Specialists, Marina and Michelle, practice Motivational Interviewing at a recent training. Photo courtesy of Kayelee Miller, all rights reserved.)
(Photo - More Motivational Interview training for local care coordinators and community health workers at a recent training in Wenatchee. Photo courtesy of Kayelee Miller, all rights reserved.)
A Pathways Community Specialist is similar to a community health worker, according to Kayelee, “[They are like a] community peer that knows how to communicate with the people being served in a way that motivates and educates. It’s different than a ‘professional’ communicating to a patient.”Pathways Community Specialists communicate with medical providers and social service agencies on a variety of issues including behavioral health, family planning, housing, immunizations, medication management, pregnancy, and postpartum.
(Photo - Pathways Community HUB is designed to address 20 different risk factors. Each risk factor is translated into a "Pathway" which has a series of specific steps that if followed, will result in the elimination or reduction of the risk factor. Pathways Community HUB Institute, all rights reserved.)
Back to Emma and Alex….
Once Emma and Alex have been determined eligible for the HUB program, they meet with their Pathways Community Specialist. They may meet at Emma and Alex’s apartment, at the clinic, or anywhere that is easiest for the client.“For clients experiencing homelessness, we are trained to ask ‘Where can I find you?’” says Kayelee. She and the three Pathways Community Specialists employed by the HUB have been through nearly seven weeks of classroom and field training.When Emma’s Pathways Community Specialist comes to meet with Emma and Alex, they will answer a series of intake questions to identify health risk factors that Emma and Alex may be experiencing. Each client’s health risk factors vary. The Pathways Community Specialist will then work with Emma to choose her priority risk factors and identify which she would like to address first.Once a risk factor has been identified, it translates into a Pathway. A Pathway is a series of specific steps that if followed, will result in the elimination or reduction of the risk factor. Risks are managed one at a time. So in this case, Emma and her Pathways Community Specialist agree to focus on employment.Emma’s Pathways Community Specialist will work with Emma to complete and update her resume and monitor Emma’s job application process at least every two weeks. The Employment Pathway will be considered complete when Emma has found a steady source of income and has been employed for 30 days or more.
(Photo - Pathways Community HUB model funds outcomes, which helps incentivize care coordination agencies to stay in regular contact with a client to ensure a Pathway is completed. Pathways Community HUB Institute, all rights reserved.)
Emma’s Pathways Community Specialist will continue to meet with Emma until all of the identified Pathways are done. This means that they are either completed or finished but incomplete. Once the Pathways are resolved, Emma and Alex will be discharged from the HUB but their information is retained in case they require assistance in the future.
(Photo - Local area care coordinators and community health workers show off their training completion certificates, Wenatchee, WA. Photo courtesy, Kayelee Miller, all rights reserved)
“The gift Pathways Community Specialists have is the time to spend with the clients. The time and the ability to listen with the clients in a way that providers don’t always have the time to,” says Deb. The repeated visits between clients and care coordinators do make a difference, studies show. By addressing a variety of client needs, the HUB model will work to reduce unnecessary ER visits, which will in turn, reduce unnecessary healthcare spending.By reducing the number of ER visits, there is less burden placed on the healthcare system. This means less staff time devoted to costly emergency care, which allows healthcare systems to focus on preventative care. “People are coming to the ER more than 50 times a year because they need someone to talk to. If we can get those people to support groups, or a senior center, or a warming shelter, then we will see a lot less people in the Emergency Department,” says Kayelee.To date, the Pathways Community HUB operating in Moses Lake already has 7 enrolled clients, with another 146 individuals who are eligible for the HUB’s care coordination services.
