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It Takes a Village: How to Coordinate and Pay for a Community Response to Health Inequities

This week, our In Focus section reviews the Pathways HUB model, an approach designed to help coordinate outreach by specialized community health workers who are incentivized to engage high-need populations. An HMA webinar, held May 9, 2019, with Mark Redding, co-developer of the Pathways HUB model, and Heidi Arthur, HMA can be viewed here.

A range of social, economic and environmental factors drive persistent health inequities and require comprehensive attention, cross sector coordination, and community-led collective effort. Community-Based Organizations (CBOs) are important partners in advancing health equity goals. They address the social determinants of health, have direct connections to the highest need populations that healthcare systems most often wish to reach, and they can offer interventions that impact overlapping clinical and social service needs among high-risk groups.

Yet, CBOs face many challenges in delivery system engagement. From funding and operational challenges to IT and workforce limitations, the question of how to activate local systems of care and finance sustainable CBO engagement has led a number of states and communities across the country to invest in innovative new models.

One approach, the Pathways HUB model, is an evidence-based, population-focused, pay-for-performance (P4P) care coordination model that identifies and addresses the comprehensive array of interrelated risk factors experienced by targeted populations within a defined geographic area. It engages local CBOs within the healthcare delivery system via a sustainable managed care financing infrastructure to coordinate efforts and standardize metrics among local community health workers (CHWs).

The model establishes a community-owned and operated HUB able to contract with multiple payers. HUBs coordinate outreach by specialized CHWs who are incentivized to find and engage the area’s highest need populations. CHWs identify and address standardized health risks via shared metrics or standardized “Pathways” that have demonstrated impact on the social determinants of health.

An early adopter managed care organization (MCO) achieved significant reduction in neonatal admissions and, for every dollar spent on Community HUB activities, realized a savings of $2.36. The model has a formal research base related to maternal and child health, but is broadly responsive to population health goals and has been utilized for an array of populations.

The model helps delivery systems and local communities effectively activate the capacity of existing CBOs and civic resources to operate as extenders to the formal delivery system under a pay for performance methodology that systematically identifies and reduces risk factors while also supporting local population health planning with multiple payers.

It specifically addresses the need for an infrastructure to support resource sharing and delivery system financing for the smallest, grassroots and locally connected CBOs that are best able to build meaningful relationships at the community level, harness formal and informal resources, and make connections to health care benefits and providers, plus human services to address the SDOH.

HUBs are able to coordinate participating CBOs to address gaps in the system of care (Pathways for which services are not available or insufficient) via the HUB’s ability to braid and blend funding from health and human services contracts.

The Pathways HUB Model has been recognized by the Institute for Healthcare Improvement, Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality (AHRQ), National Institutes of Health, CMS Innovation Center, HRSA, and National Science Foundation, and is the predominant approach adopted in Washington State’s Accountable Communities of Health.

HUBs are active in Ohio, Michigan, Oregon, Texas, New Mexico, Wisconsin, Minnesota. HUBs are being planned in Pennsylvania, North Carolina, South Carolina, Connecticut, Virginia. Community coalitions in five other states are exploring the model.

The HUB represents a local “care traffic control center” for the participating network of community-based health and human services agencies. The HUB contracts with payers and funders, oversees quality, and administers data collection and billing claims on behalf of the member organizations. The HUB ensures that care coordinators and providers within the system of care routinely collaborate in their approach to identify and address risks, identify service gaps for targeted investment, and avoid service duplication.

Working with a team of social workers and medical personnel, CHWs who have strong local connections and resource knowledge are incentivized to identify, reach out, and engage the individuals and families who have the most serious risk factors and the poorest health outcomes. CHWs develop a risk reduction plan of care based on a comprehensive assessment of medical, social and behavioral health risk factors for each identified individual within a family. Each risk factor identified in the assessment is assigned a specific Pathway that is tracked in order to ensure it is appropriately addressed. There are 20 nationally standardized Pathways. These Pathways, and associated risk reduction interventions, span access to health and behavioral health care, housing, food stability, education, and employment. The model is a pay-for-performance approach in which salaried CHWs can earn incentive payments for mitigating health risks. Programs delivering nationally certified HUB model services are paid when each Pathway (risk reduction) is completed.

The HUB model advances a community response for individuals and for local systems of care. At the individual level it brings together CBOs, local service providers, funders, and community members as part of the intervention team.  The Pathways HUB model does not provide direct medical or social services. Instead, the model works to identify those at risk, assess their health and social service needs, and ensure they are connected to necessary critical interventions to address those needs.  At the system of care level, the HUB serves as a central organizing structure for a local network of CBOs that are most often small entities experienced in an array of different services.

The HUB is an objective, quality focused agency able to effectively represent its network of community-based agencies and the individuals it serves. Each HUB has an advisory board and uses Pathways data, plus other related community assessment approaches, to ensure that the HUB is focused on the needs of the local community and that its guidance and leadership comes from the HUB’s service region.  It is recommended that HUBs not be part of a national or state network of agencies that may have to abide by state or national guidance and requirements that might differ from the local needs of the community.

Ideally, a local not-for-profit is developed whose sole purpose is to serve as the HUB. The HUB also represents CBOs for contracting with a variety of different funding entities including managed care organizations, grant makers, and public health departments. Working together as an organized team of agencies, the HUB network identifies those at greatest risk and ensures they are connected to CHWs from the community who are the frontline force for outreach and care coordination among the appropriate medical, social, and behavioral health interventions.

HUBs most often develop from a well-connected group of individuals within a community who form a network focused on outcome improvement.  Often there are one or more “community change agents” or leaders who can bring the individuals, agencies, and combined interests of the community together to accomplish their goals. Technical support through the Pathways Community HUB Institute and a CBO engagement toolkit available from HMA is available to assist in this process. PCHI is responsible for the national standards and certification of HUBs and has committed to ongoing modification of the standards, based on scientific evidence.

To learn more about the Pathways HUB model and how to build CBO capacity and HUB readiness in your community, contact:

Heidi Arthur at [email protected]