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Service Delivery Innovation Profile

Program Uses "Pathways" to Confirm Those At-Risk Connect to Community Based Health and Social Services, Leading to Improved Outcomes


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Snapshot

Summary

The Community Health Access Project (CHAP) implemented the Pathways Model, which employs community health workers who connect at-risk individuals to evidence-based care through the use of individualized care pathways designed to produce healthy outcomes. This model promotes timely, efficient care coordination through incentives and prevents service duplication through use of a Community Hub, a regional point of patient registration, and quality assurance supporting a network of agencies involved in providing care to the target population. The first implementation of the model in Richland County, OH, resulted in increased services to at-risk women and a decline in the rate of low birth weight babies.

Evidence Rating (What is this?)

Moderate: The evidence for enhanced access to care consists of documentation of completed Pathways and pre- and post-implementation comparisons of the number of clients served. The evidence for lower rates for low birth weight consists of a comparison of pre-implementation rates in two targeted areas of Richland County to post-implementation rates in a sample of 300 clients who live in the same areas.
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Developing Organizations

Community Health Access Project
Mansfield, OHend do

Use By Other Organizations

As of June 2010, AHRQ has supported the development of the Care Coordination Learning Network representing 16 communities across the United States using a Pathways-based care delivery system.
  • Placerville, CA
  • Indianapolis, IN
  • Boston, MA
  • Muskegon, MI
  • Kansas City, MO
  • Lincoln, NE
  • Albuquerque, NM
  • Rio Arriba, NM
  • Cincinnati, OH
  • Mansfield, OH
  • Toledo, OH
  • Oklahoma City, OK
  • Portland, OR
  • Bend, OR
  • Dallas, TX
  • Washington State

Date First Implemented

2001
The Community Health Access Project formed in 1999 and implemented the Pathways Model in 2001.begin pp

Patient Population

Gender > Female; Vulnerable Populations > Womenend pp

Problem Addressed

At-risk populations commonly suffer poor health outcomes for many reasons. In particular, low birth weight newborns are common in at-risk communities, often because of barriers to accessing high-quality prenatal care.
  • 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, OH, with unusually high rates of low birth weight babies, averaging more than 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 (e.g., 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 can access evidence-based services, nor do they effectively track the efficiency or quality of services provided.

What They Did

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Description of the Innovative Activity

To address the problem of birth weight disparities in Richland County, OH, the Community Health Access Project (CHAP) implemented the Pathways Model, which uses community health workers, nurses, and social workers as care coordinators who connect at-risk individuals to evidence-based care through the use of "Pathways" designed to produce healthy outcomes. The program has three overarching principles—identifying those at greatest risk, treating those at risk by providing access to evidence-based health care and social services, and measuring outcomes by documenting and evaluating benchmarks. This model promotes timely, efficient care coordination through incentives and prevents service duplication through use of a Community Hub or network of related agencies involved in providing care for the target population. Key elements of the model and its initial implementation in Richland County include the following:
  • 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. According to information received in June 2010, over the past 2 years CHAP has received an increasing number of referrals of at-risk pregnant women identified by the Medicaid Managed Care program as part of its participation in the Community Hub.
  • Developing and implementing individually tailored Pathways for at-risk clients: The program created specific Pathways to serve as accountability tools to document engagement of the at-risk individual and connection to intervention(s), and to measure outcomes. 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 care plan: Using previously developed and standardized Pathways, community health workers and other care coordinators developed a care plan that listed which Pathways each client needed. 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 may not be necessary in other systems that use nurses or social workers as care coordinators.
    • Implementing 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 and evidence-based interventions received, and assisting with follow up 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 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. Although 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, along with financial incentives based on the number of Pathways completed, the number of clients served, and the number of quality assurance points earned (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.

Context of the Innovation

CHAP is a nonprofit organization started in Mansfield, OH, in 1999 with the goal of overcoming barriers to health care and employment for residents of the Ocie Hill neighborhood. Mark Redding, MD, and Sarah Redding, MD, were inspired to develop the model by their experience with community-based outreach in Kotzebue, AK, as part of Alaska's Community Health Aide Program. CHAP initially implemented the Pathways Model with a focus on reducing the incidence of low birth weight babies in Richland County, OH. Today, CHAP provides a recognized model of community-based care coordination as a means of improving the basic health and social outcomes of at-risk individuals, and collaborates with other organizations across the country to achieve health equity and improve performance on a variety of outcomes measures.

Did It Work?

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Results

CHAP's initial implementation of the Pathways Model in Richland, OH, resulted in increased services to at-risk women, leading to a significant reduction in the rate of low birth weight babies.
  • Enhanced access to care: According to information received in June 2010, CHAP has documented the completion of 10,000 individual Pathways at three sites within targeted geographic areas. The number of completed Pathways rose steadily to 100 to 200 per month at each of the three sites, and these levels have been sustained over time. In Richland County, the number of at-risk pregnant women served increased from 19 to 146 in 1 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 more than 23 percent.

Evidence Rating (What is this?)

Moderate: The evidence for enhanced access to care consists of documentation of completed Pathways and pre- and post-implementation comparisons of the number of clients served. The evidence for lower rates for low birth weight consists of a comparison of pre-implementation rates in two targeted areas of Richland County to post-implementation rates in a sample of 300 clients who live in the same areas.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Identification and training of community health workers: CHAP researchers identified the census tracts with the highest rates of low birth weight and poverty. They 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, 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. Program leaders developed Health Insurance Portability and Accountability Act (HIPAA)–compliant forms and later a HIPAA-compliant database.
  • Expansion to other counties: In February 2000, CHAP expanded to rural Knox County, where Appalachian and Amish clients receive care coordination services.

Resources Used and Skills Needed

  • Staffing: The major staff positions include care coordinators and their supervisors, along with the director and staff of the Community Hub. Each care coordinator is typically drawn from or otherwise reflects the local community being served, and 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 documentation of results in the Pathways, and providing reports to monitor quality and contractual payments to the agencies. In most communities, a community board with broad representation oversees the Hub.
  • Costs: As of 2009, the average cost of intensively case managing a pregnant or other high-risk client for 1 year is approximately $1,000. These costs may be somewhat lower today, because more local and state funders are using the Community Hub (as of June 2010), thus driving down administrative costs for each participating agency.
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Funding Sources

American Academy of Pediatrics; Ohio Department of Job and Family Services; Osteopathic Heritage Foundations; Medicaid Managed Care
CHAP is funded by the Ohio Department of Job and Family Services and through other grants and contracts, including the aforementioned grant from the American Academy of Pediatrics.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Establish coalition: Include community members, private business members, health and social service professionals, funders, and policy makers.
  • Start with desired 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 Pathways as quality assurance tools: The Pathways should clearly document the targeted at-risk population, information on barriers this population faces, the connection of individuals to the prescribed services, and a measurable outcome.
  • Develop quality assurance protocols: Build strong quality assurance guidelines and protocols at the outset, and make adjustments as new opportunities arise. Quality assurance should focus on the program's target outcomes.
  • Find initial "bold" funder: Securing initial and ongoing funding represents the greatest challenge in building this kind of program. Funders may not be 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.
  • Conduct needs assessment, train accordingly: 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. As new community health workers come on board, such training efforts must be continued.

Sustaining This Innovation

  • Use current community health workers/care coordinators to recruit new ones: Once a community health worker program is up and running, existing care coordinators often represent the best mechanism for identifying and recruiting qualified individuals to serve as new staff.
  • Support care coordinators when poor outcomes occur: Because care coordinators who work with at-risk clients face very challenging circumstances, program leaders need to develop strategies to support them when a client dies or suffers another type of poor outcome.
  • Encourage administrative staff to go on home visits: Getting administrative personnel involved and connected to the care coordinators' work can assist in their professional development.
  • Reach into low-income neighborhoods: Support care coordinators in their outreach activities to low-income urban and rural neighborhoods, including hard-to-access (and often forgotten) house trailers.
  • Use appropriate reporting and evaluation strategies: Ongoing reporting and evaluation can support continuous quality improvement and cost reduction. Appropriate reporting also ensures that agencies receive payments based on completion of Pathways.
  • Track measures other than 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 the number of initiated Pathways, the number not completed, the most common barriers for individuals trying to connect clients to evidence-based care, and which care coordinators perform 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

As of June 2010, AHRQ has supported the development of the Care Coordination Learning Network representing 16 communities across the United States using a Pathways-based care delivery system.
  • Placerville, CA
  • Indianapolis, IN
  • Boston, MA
  • Muskegon, MI
  • Kansas City, MO
  • Lincoln, NE
  • Albuquerque, NM
  • Rio Arriba, NM
  • Cincinnati, OH
  • Mansfield, OH
  • Toledo, OH
  • Oklahoma City, OK
  • Portland, OR
  • Bend, OR
  • Dallas, TX
  • Washington State

More Information

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Contact the Innovator

Mark Redding, MD, FAAP
Sarah Redding, MD, MPH

Community Health Access Project
35 North Park Street, Suite 132
Mansfield, Ohio 44902
Phone: (419) 525-2555
Fax: (419) 525-2558

E-mail: reddingmark@att.net or sredding@att.net

Innovator Disclosures

Dr. and Dr. Redding have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

The Community Health Access Project is available at http://www.chap-ohio.net/.

Examples of other programs based on the Pathways© Model include the following:

County-Wide Collaborative Uses Pathways Model to Enhance Access to Insurance, Primary Care and Mental Health Services for Low Income Children. AHRQ Health Care Innovations Exchange. Available at: http://www.innovations.ahrq.gov/content.aspx?id=2391

Pathway Helps Massachusetts Residents Develop and Implement Debt-Reduction Strategies, Leading to 60-Percent Reduction in Medical Debt. AHRQ Health Care Innovations Exchange. Available at: http://www.innovations.ahrq.gov/content.aspx?id=2128

Volunteer Provider Network Cares for Uninsured Working Poor, Leading to Lower Utilization Costs, Better Outcomes, and Positive Return on Investment. AHRQ Health Care Innovations Exchange. Available at: http://www.innovations.ahrq.gov/content.aspx?id=2228

Michigan Pathways Project Links Ex-Prisoners to Medical Services, Contributing to a Decline in Recidivism. AHRQ Health Care Innovations Exchange. Available at: http://www.innovations.ahrq.gov/content.aspx?id=2134

Footnotes

1 Martin JA, Hamilton BE, Sutton PD, et al. Births: Final Data for 2006. National Vital Statistics Reports; vol 57, no 7. Hyattsville, MD: National Center for Health Statistics. 2009. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 Goldenberg RL, Culhane JF. Low birth weight in the United States. Am J Clin Nutr. 2007;85(2):584S–90S. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 27, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 15, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.