|By the Innovations Exchange Team|
A new study funded by the National Science Foundation (NSF) used a systems engineering approach to formalize a community care coordination model, providing a better understanding of its operations and processes. The data generated from this modeling and testing have provided new insights into the Pathways Community HUB Model that will inform the design of the model’s certification program currently under development. These are the first results from this ongoing effort to study the application of simulation and modeling approaches to health care systems.
The Innovations Exchange interviewed the NSF study’s co-principal investigator Bernard Zeigler, PhD, and study team member Sarah Redding, MD, MPH, who, with Mark Redding, MD, developed the Community Health Access Project (CHAP) and the Pathways Model.
Innovations Exchange: How do pathways in the model facilitate care coordination?
Sarah Redding, MD, MPH: A pathway is a structured process that uses community care coordinators to identify, define, and resolve a health or social service problem. Each pathway represents one issue that is tracked through to completion and a measurable outcome. For example, the Pregnancy Pathway ends with a normal birth weight infant, and the Social Service Referral Pathway ends with a confirmed appointment with a social service provider.
The Ohio CHAP in Mansfield developed the Pathways Model to improve the health and preventive care of high-risk women and their children in underserved areas. The Ohio CHAP developed the first pathway focused on pregnancy to improve low birth weight outcomes among African-American women. The program has since developed 16 additional pathways to address other issues experienced by high-risk women, including homelessness, access to a medical home, smoking, immunizations, lead exposure, and childhood behavior problems.
How did the community HUB concept evolve from the pathways?
Redding: After CHAP achieved significant positive outcomes using the Pregnancy Pathway, we expanded its use to other agencies serving pregnant women in Richland County. We developed a centralized data collection site called a HUB at the community level to track the various agencies using the pathways to facilitate coordination of services, evaluation, and quality assurance.
What insights did you gain from your analysis about the HUB model's potential to improve birth outcomes among disparate populations?
Bernard Zeigler, PhD: We realized that the referral source of clients to the CHAP program made a difference in birth outcomes. Our analysis showed that African-American women who were referred from community-based care sources received more coordinator attention, showed greater adherence to their assigned tasks, were more likely to remain in the program, and had a higher percentage of normal births than the predominantly white women referred by the Medicaid managed care plans. The community-based enrollment process is quick and personal, leading to high retention and effective intervention.
Redding: The difference in birth outcomes highlights the importance of keeping programs at the community level. For example, Richland County has received grants from the Ohio Infant Mortality Reduction Initiative for the past decade. The county hired local African-American care coordinators who quickly engaged African-American women in early prenatal care by canvassing the local Medicaid office, obstetrician offices, and community-based organizations. In contrast, the Medicaid managed care plan requires women to see an obstetrician to get a referral, which has to go through claims processing and risk scoring at the plan level. This administrative process causes significant delays in enrolling women into the CHAP program and receiving prenatal care.
How does the Pathways Model address accountability at the systems level?
Redding: When payers contract with a community HUB, the payments are based on completed pathways and measurable outcomes. This pay-for-performance model is based on the outcomes that a care coordinator achieves with a client. The largest payers tend to be Medicaid managed care plans, which select both the pathways and their reimbursement. Typically, HUBs receive an initial payment after they engage clients and conduct an initial assessment. The remaining payments are made after a pathway is completed. Payers like this model because payment is tied to results.
Zeigler: Our data analysis shows that outcomes-based payments in plan contracts lead to higher rates of pathways completion, compared with contracts without outcomes-based payments.
Should Healthcare Effectiveness Data and Information Set (HEDIS) measures be tied to pathways payments?
Zeigler: HEDIS measures are not the best way to approach payment for pathways, because payers may select only action steps that have HEDIS measures to reimburse and may ignore other critical steps. For this reason, we recommend that payers reimburse agencies for completing the entire pathway.
Redding: In our contracts with Medicaid managed care plans, payments are aligned with HEDIS measures because those are what plans are held accountable for; however, there are no HEDIS measures for certain social services, although they play an important role in achieving positive pregnancy outcomes. For example, the HEDIS measure for postpartum planning requires only that a patient keep an appointment. To keep that postpartum appointment, other barriers not directly related to health care may need to be addressed, such as child care and transportation. We are trying to help payers think beyond getting clients to their medical appointments, and to understand that actions related to social determinants will lead to better outcomes.
Did you develop new measures for pathways, and what impact did those measures have?
Zeigler: Our analysis identified several steps common to many pathways that were critical to the overall achievement of outcomes and that provided important opportunities for process measurement and improvement. For example, we developed new measures for care coordinator competency because we found that many pathway reports were incomplete or inconsistent. We also developed measures for client adherence; these document the client's role in completing pathway steps, such as keeping appointments. With the creation of these measures, we found that care coordinator competency in turn improved client adherence to the pathways, client retention, and pregnancy outcomes.
Redding: If you have an experienced, well-respected, and organized care coordinator, he or she is more likely to achieve successful outcomes with clients.
Did the formalization of pathways in the NSF study lead to improvements in care coordination?
Zeigler: The formal representation of pathway action steps provided a lens to examine the data, obtain insights, and make recommendations for improvements in coordination. For example, we discovered that the community care coordinator’s competency and community-based experience affects client retention and adherence, and that having standard and reimbursable metrics for some pathways or steps may improve client adherence. As a result, we recommend a consistent payment scheme that covers the entire pathway, including nonmedical pathway elements such as social services.
Redding: The data enabled us to better understand successful and unsuccessful elements of the Pathways Model; for example, the competency measures led us to understand the relationship between frequency of community care coordinators’ reporting and pregnancy outcomes.
How will formalization enhance the Community HUB certification process?
Zeigler: Formalization provides a well-defined means for developing a uniform description of standard pathways that can also be used for new pathways as they are introduced in practice. Formalization is designed to support the implementation of recently developed standards for organizations that aim to achieve community HUB certification.
Redding: The formalization is critical for the certification process being developed for any Pathways Community HUB entity. This is a service delivery system model, so we need more information to improve the system and its outcomes, especially as we expand our target population beyond mothers and children to patients with chronic diseases.
When will the certification process be rolled out?
Redding: It is a 3-year process, and we have just finished the first year of implementing the draft certification requirements at three pilot sites in Michigan, Ohio, and New Mexico. We will also review information from functioning HUBs to incorporate into the project.
About Bernard Zeigler, PhD: Dr. Zeigler is Emeritus Professor of Electrical and Computer Engineering at the University of Arizona and an adjunct research professor in the C4I Center at George Mason University. He is internationally known for his seminal contributions in modeling and simulation theory and has published several related books. He was named Fellow of the Institute of Electrical and Electronic Engineers for the discrete event system specification (DEVS) formalism that he invented in 1976. Among numerous positions held with the Society for Modeling and Simulation International, he served as president and was inducted into its Hall of Fame. He is currently chief scientist with RTSync Corp., a developer of the MS4 modeling and simulation software based on DEVS.
About Sarah Redding, MD, MPH: Dr. Redding is Chief Executive Officer for Care Coordination Systems. Previously, she was the executive director of the CHAP in Mansfield, OH, a nonprofit organization employing community care coordinators that she helped start in 1999. Dr. Redding has been involved with community care coordinators for more than 20 years and was instrumental in obtaining State certification through the Ohio Board of Nursing. She has worked to develop and implement pathways and the Pathways Community HUB Model. Her recent work has focused on community care coordination to address health disparities, and she is the co-director of the National Center for Community Care Coordination, a partnership between CHAP and the Rockville Institute for the Advancement of Social Science Research.
Dr. Zeigler reported that RTSync Corp. received an NSF grant to study the formalization of the Pathways Model and that he received payment from the NSF grant as the study’s co-principal investigator.
Dr. Redding reported that she received reimbursement from AHRQ to attend meetings of the AHRQ Community Care Coordination Learning Network from 2008 to 2011 when she was CHAP’s Executive Director; CHAP also received an honorarium on her behalf. Dr. Redding received payment from the NSF study grant for her participation as a team member. She holds a leadership role in Care Coordination Systems, a company which is developing tools for communities that seek to implement a Pathways Community HUB model.
Innovation Profile: Program Uses "Pathways" To Confirm Those At-Risk Connect to Community Based Health and Social Services, Leading to Improved Outcomes http://www.innovations.ahrq.gov/content.aspx?id=2040
QualityTool: Connecting Those at Risk to Care: A Guide to Building a Community "HUB" To Promote a System of Collaboration, Accountability, and Improved Outcomes