Community Health Workers Develop "Pathways" to Facilitate Access to Needed Services For At-Risk Populations, Leading to Improved Outcomes

Problem Addressed

• Rising low birth weight and preterm birth rates: Since 1990, the national rate of low birth weight babies has risen by more than 16 percent, while preterm births (defined as births before the completion of the 37th week of pregnancy) have risen by more than 20 percent.¹ A newborn's birth weight is a key predictor of infant health, and low birth weight can lead to costly yet preventable medical expenses.²
• Birth weight disparities in Richland County: The program initially focused on two neighborhoods in Richland County, Ohio, with unusually high rates of low birth weight babies, averaging over 23 percent (more than 3 times the overall county average).
• Inefficient care coordination for at-risk individuals: In Ohio and other states, responsibility for care coordination rests with multiple state agencies, which often leads to duplicative programs and services. For example, a pregnant woman living in extreme poverty may have many different care coordinators, each representing a substantial expense to the State. Yet, she still may not receive adequate access to care, because these agencies are paid based on deliverables (such as phone calls made or notes charted) that do not represent confirmed benefit to the individual served.  These agencies rarely measure how barriers are addressed so that clients actually access evidence-based services, nor do they effectively track the efficiency or quality of services provided.

Description of the Innovative Activity

• Identifying at-risk populations: The Pathways^© Model uses neighborhood-specific health data through a process known as "geocoding" to identify high-risk areas that serve as the target population for an intervention. This strategy can be used for most health and human services issues for which data are available. In Richland County, CHAP reviewed birth certificates for a 5-year period, plotting the addresses of low birth weight babies on a county map. This process led to the identification of two areas that represented 7 percent of the county's population but accounted for 30 percent of all low birth weight babies. CHAP decided to target families in these areas who faced significant barriers in accessing health care services.
• Developing and implementing individually tailored Pathways for at-risk clients: Pathways outline the critical steps related to care coordination and other services that are needed for an individual to achieve a positive outcome based on his or her specific health and social conditions. CHAP developed and implemented Pathways for families in Richland County through the following key steps:
  • Initiation of new clients via home visits: Community health workers reached out to at-risk individuals through home visits, informing them about care coordination services and enrolling those interested in participating. Using a checklist, they assessed each individual's health status (including social and behavioral health status), housing and employment situation, and other dynamic areas of the individual's life, with the purpose of identifying any problem areas to be addressed, along with desirable outcomes that could be attained, through Pathways.
  • Development of initial Pathway(s): Using previously developed and standardized Pathways, community health workers and other care coordinators developed a care plan that listed which Pathways each client would be assigned. For example, if a client needed housing, food, prenatal health checkups, and a medical home, she was assigned to the Housing, Social Service Referral, Pregnancy, and Medical Home Pathways.
  • Pathway approval: In the CHAP system, a supervisor, typically a nurse or social worker, reviewed all demographic, health, and social service information before community health workers could begin implementing a new Pathway. This step is not necessary in other systems that use nurses or social workers as care coordinators.
  • Implementing the Pathway: Community health workers and other care coordinators followed the evidence-based action steps outlined in the Pathways, with specific steps depending on the outcome being worked toward. Key steps included:
    • Providing standardized education to the client and/or family members.
    • Identifying and eliminating barriers to receiving services, such as transportation, health insurance coverage, fear of the physician’s office, and language and cultural barriers. Because lack of access to food, housing, employment, education, and other basic necessities may trump prenatal care as a priority for pregnant women, care coordinators attempted to address these social determinants of health as well.
    • Confirming that appointments were kept, evidence-based interventions were received, and assisting with followup services and compliance with treatment plans. This step often involved following up with patients on the phone or in person.
  • Documentation and completion of Pathways: Community health workers and other care coordinators documented each step electronically or on paper as it was completed, thereby using the Pathway as a data collection and evaluation tool. A Pathway is considered "completed" when a final, positive outcome can be documented. While the defined outcome is usually related to health, it can also relate to an improvement in employment, education, housing, or other social conditions that affect health status.
• Financial incentives for community health workers: CHAP community health workers received a competitive salary and benefits and were also given financial incentives based on the number of Pathways completed, the number of clients served, and the number of quality assurance points earned (these points are based on chart reviews conducted by supervisors).
• Creation of network of related agencies or "Community Hub": The Pathways^© Model includes a regional care coordination delivery strategy, focusing on outcome production across a network of care coordination agencies, including health agencies, hospitals, social service providers, local funders, private businesses, and other organizations. These agencies are tied together into a network or "Community Hub" that serves as a central registry to help the agencies work together without duplicating services. In Richland County, seven care coordination agencies targeting maternal and child health used the Community Hub to track service to pregnant women in high risk areas. Each care coordination agency focused on a specific at-risk census tract, thus ensuring that those clients most at risk were being served without duplicating services.
• Tying agency payment to Pathways: The Community Hub also tracked progress, including the completion of Pathways by clients at participating agencies. The structure of payments to network agencies is no longer based on process measures (e.g., phone calls and documentation of client lists) but rather on outcomes such as confirmed connections to obstetrical visits and delivery of normal birth weight babies.

References/Related Articles

Contact the Innovator

Results

• Enhanced access to care: CHAP has documented the development of 10,000 individual Pathways in three sites within targeted geographic areas. The number of completed Pathways rose steadily to between 100 and 200 per month at each of the three sites, and these levels have been been sustained over time. In Richland County, the number of at-risk pregnant women served increased from 19 to 146 in one year, a level that has been maintained over 3 years.
• Reduced rate of low birth weight babies: The low birth weight rate in two targeted areas of Richland County fell significantly after implementation of the program. Data from more than 300 clients shows a low birth weight rate of less than 5 percent; the majority of these clients live in impoverished areas that previously had a low birth weight rate of over 23 percent.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Identification and training of community health workers: CHAP researchers identified the census tracts with the highest rates of low birth weight and poverty. They then used local churches and community-based organizations to identify women living in the at-risk communities who could serve as community health workers. Project leaders developed a 12-credit hour training program, which was implemented through the local community college in a culturally and educationally appropriate manner. Training focused on how to function as part of a health care team serving at-risk patients, and promoted team building and networking among community health workers. Training consisted of 3 weeks of intensive instruction followed by several months of practical instruction provided 1 day per week.
• Formation of Community Hub: The Community Hub began with the support of an American Academy of Pediatrics Community Access To Child Health Grant. Project leaders conducted a community needs assessment involving more than 70 health and social service agencies, with the community prioritizing the health and social service issues identified. Participating agencies developed community-wide Pathways to address each of the priority areas, including pregnancy, immunizations, child development, lead screening, and others. All participating agencies received training and developed outcome contracts. Health Insurance Portability and Accountability Act (HIPAA)-compliant forms and later a HIPAA-compliant database were developed. 
• Expansion of program to other counties: In February 2000, CHAP expanded to rural Knox County, where Appalachian and Amish clients are among those receiving care coordination services. In 2001, the program expanded to the inner-city area of Columbus, OH.

Resources Used and Skills Needed

• Staffing: The major staff positions are care coordinators and their supervisors, along with the director and staff of the Community Hub. Care coordinators are drawn from or otherwise reflect the local community being served, and each one typically manages 35 to 70 clients. The Community Hub is staffed by a director and a handful of other individuals responsible for supporting the network of community agencies by maintaining the database or paper system to eliminate duplication, confirming that results are documented in the Pathways, and providing reports to monitor quality and contractual payments to the agencies. In most communities, the Hub is overseen by a community board with broad representation.
• Costs: Primary costs relate to compensation for the care coordinators. The average cost of intensively case managing a pregnant or other high-risk client for 1 year is approximately $1,000.  

Funding Sources

American Academy of Pediatrics; Ohio Department of Job and Family Services

Getting Started with This Innovation

• Establish a coalition: Include community members, private business members, health and social service professionals, funders, and policy makers.
• Choose the service location carefully: Care coordination programs work best when they are located within the community being served.
• Clearly specify target outcomes: Define the health and social conditions to be addressed, and build Pathways accordingly. Clearly defined goals and target outcomes help to shape the development of other program components.
• Develop quality assurance protocols: Build strong quality guidelines and assurance protocols at the outset, and make adjustments as new opportunities arise. Quality assurance should focus on the program's chosen target outcomes.
• Find an initial "bold" funder: The greatest challenge in building this kind of program is securing initial and ongoing funding. Funders are often not accustomed to contracts that pay based on achievement of meaningful outcomes rather than process measures. Networking with State and/or Federal agencies might be helpful in identifying an initial "bold" funder, which in turn may encourage other funders to join the program once they see documented evidence of success.

Sustaining This Innovation

• Use current community health workers to recruit new ones: Once a community health worker program is alive and well within a community, existing community health workers are often the best mechanism for identifying and recruiting qualified individuals to serve as new staff.
• Support care coordinators when poor outcomes occur: Care coordinators who work with at-risk clients face very challenging circumstances. Care coordinators can be community health workers, social workers, nurses, or others working in impoverished communities. Develop strategies to support care coordinators when a client dies or suffers some other poor outcome.
• Encourage administrative staff to go on home visits: Getting administrative personnel more involved and connected to the care coordinators' work can assist with their professional development.
• Stay connected to the community and the individuals being served: Begin with a detailed needs assessment and ensure that all services are provided in a culturally appropriate manner. Provide adequate training to ensure that all care coordinators have the communication skills, trust, and critical wisdom necessary to navigate and network effectively in the community.
• Reach into low-income neighborhoods: Support care coordinators in their outreach activities to low-income urban and rural neighborhoods, including to hard-to-access (and often forgotten) house trailers.
• Track measures other than the number of Pathways completed: In addition to project-specific outcomes (e.g., the rate of low birth weight babies for a program working with at-risk pregnant women), other measures to examine include how many Pathways are initiated, how many are not completed, what are the most common barriers for individuals trying to connect clients to evidence-based care, and which care coordinators perform the best. The ability to document confirmed improvements in health and social service outcomes, along with related cost savings, can be of great help in making the case for sustainability moving forward.

Use By Other Organizations

• Placerville, CA
• Indianapolis, IN
• Kansas City, MO
• Lincoln, NE
• Albuquerque, NM
• Rio Arriba, NM
• Cincinnati, OH
• Mansfield, OH
• Toledo, OH
• Oklahoma City, OK
• Portland, OR
• Washington State