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September 2010
Connecting Those At-Risk to Care: A Guide to Building a Community "HUB"
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Connecting Those at Risk to Care: A Guide to Building a Community "HUB"

Web Event
September 16, 2010
Host: Judi Consalvo, US Agency for Healthcare Research and Quality

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What Is the Health Care Innovations Exchange?

Searchable database of service innovations

  • Includes successes and attempts
  • Wide variety of sources, including unpublished materials
  • Vetted for effectiveness and applicability to patient care delivery
  • Categorized for ease of use—extensive browse and search functions
  • Includes innovators’ stories and lessons learned
  • Features expert commentaries

Learning opportunities

  • Learning networks offering a chance to work with others shared concerns
  • Educational content
  • Web Events featuring innovators, experts, and adopters

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AHRQ Health Care Innovations Exchange Web Event Series

How to find archived materials

Next Event

  • Web event in November--look for the announcement


  • At the end of this Web event, please complete the evaluation.

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  • No phone is necessary for this event
  • You may just stream the audio over the Web through the speakers on your computer.
  • For help, notify the Vcall team through the question window at the bottom of the screen.
  • To refresh your screen, hit f5
  • Visit for a transcript of this Web seminar and the PowerPoint slides.

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Submitting Questions

  • When: Any time during the presentation
  • How: Send a written question through the question window

Arrow pointing to image of slide_01.

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Today's Event Moderator

Laura Brennan, MSW

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Community Care Coordination Learning Network (CCCLN)

CCCLN: Grassroots learning network of health care organizations across the country caring for @13,000 patients from vulnerable populations. Launched 2008.

16 communities represented:

  1. Albuquerque, NM
  2. Bend, OR
  3. Boston, MA
  4. Cincinnati, OH
  5. Dallas, TX
  6. El Dorado Hills, CA
  7. Espanola, NM
  8. Indianapolis, IN
  9. Kansas City, MO
  10. Lincoln, NE
  11. Mansfield, OH
  12. Muskegon, MI
  13. Oklahoma City, Ok
  14. Olympia, WA
  15. Portland, OR
  16. Toledo, OH

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Health Issues Addressed by CCCLN

  • Improving Pregnancy Outcomes
  • Medical Debt Elimination and Resolution
  • Medical Homes for Mothers and Infants
  • Substance Abuse Treatment Compliance
  • Securing Health Care Coverage
  • Pediatric Mental Health Consultations
  • Chronic Disease Management
  • Medical Homes and Navigation for New Parolees
  • Neurological Trauma Care

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Pathways Community HUB Manual: Overview

  • Background:
    • 2008-2009: Toolkit developed by network on how to create a community/regional infrastructure for care coordination.
    • 2010: Manual developed by a committee led by Mark Redding, MD, FAAP and Laura Brennan, MSW. CCCLN representatives also contributed.
  • Description:
    • How-to guide on building infrastructure to ensure that at risk individuals are served in a timely and coordinated manner, producing positive health outcomes.

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Pathways Model: Summary

  • A strategy for achieving measurable, positive outcomes for populations most at risk in the community and for developing action steps to accomplish those outcomes.
  • Emphasizes importance of tracking health and social service interventions at the individual, agency, and regional level using common metrics.

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Audience for HUB Manual

  • Federal, State, and local governmental agencies and community-based organizations:
    • Healthcare safety net clinics
    • Hospitals
    • Public health departments
    • Private practitioners
    • Private businesses
    • Elected officials
    • Managed care organizations/insurers
    • Charitable organizations
    • Others

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Today's Speakers

Image of Mark Redding, MD, FAAP
Image of Sarah Redding, MD, MPH

  • Champions, AHRQ Innovations Exchange Community Care Coordination Learning Network
  • Co-Developers, Pathways Model
  • Champions, Community Health Access Project (CHAP), Mansfield, OH

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Today’s Speakers

  • Director, University of New Mexico Health Sciences Center, Office of Community Affairs
  • Hub Director, Pathways to a Healthy Bernalillo County (Albuquerque, New Mexico)

Image of Leah Steimel, MPH

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The Pathways Model: Overview

Mark Redding, MD, FAAP
Sarah Redding, MD, MPH
Community Health Access Project (CHAP)
Mansfield, OH

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Pathway Model: A Tool to Measure Outcomes

Find the Target Population to engage those at greatest risk Treat to assure connection to evidence-based intervention Measure all outcomes

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Model Health Care Delivery System

Photo of Kotzebue Alaska

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Why Focus on Those At Risk?

  • Less likely to connect to prevention and early treatment today than a decade ago.
  • Health care budget has nearly tripled in that time.
  • 5% of Population = 50% of cost and greatest concentration of health disparity.

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Client Perspective

Health and Social issues are interlinked. From the client’s perspective, social issues are as important as health issues. Both must be addressed. Encouraged to use secure messages to send BP measurements to their physician.

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We Have the Evidence-Based Interventions

Adult Education

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Where is Our Delivery System?

Our current health care system does not assure that those at risk Receive/Connect to the critical packages of prevention and early treatment.

Image of man holding stack of boxes.

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Example – Pregnancy Pathway

Diagram shows the example steps for a Pregnancy Pathway.

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More Than One Pathway Needed

One client has many issues that require multiple Pathways.

Chart shows problem list, interventions and measures

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Pathways Community Hub

A Regional Delivery System Across Health and Social Services.

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Low Birth Weight Within a Single Agency Using Pathways

Graph shows positive trend after year 2003 in low birth weight within a single agency using Pathways.

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Low Birth Weight Across the Region – Implementing a Pathways Community Hub

Graph shows trends in 2 communities after implementing a Pathways Community Hub

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Richland County (OH) Community Hub: It’s a Systems Issue…

Do we serve the most at risk? Why should we?

  • 5% of population uses 50% of health care resources.
  • Most at risk are often the hardest to serve → no incentive to serve them.
  • Access for all (insured and uninsured) has gotten worse over the past 10 years.

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Pregnant Client At Risk:

Do we serve the most at risk? Why should we?

  • Her issues cross multiple agencies that function as silos:
  • Health care
  • Insurance
  • Housing
  • Education/employment
  • Mental health

…and no one is measuring the system → only the individual programs

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Women At Risk of a Poor Birth Outcome

Map of Richland County Ohio showing areas of high risk.

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Where Services Were Going…

Map of Richland Country showing services delivered in low risk areas.

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Central Registration

Central Registration – Agencies as a Team.

Illustration of all spokes of the Community Hub Model.

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Regional Team of 7 Care Coordination Agencies

Increasing Connection to Care for At Risk Pregnant Women.

Graphs show the increasing Connection to Care for At Risk Pregnancy.

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Partnerships Necessary

Community HUB – Monitors the Whole System.

Funding model for implementing the Community Hub.

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Problem Statement:

  1. Do we care about serving those in the community most at risk for poor health and social outcomes?
  2. If we do care → then we do not have the infrastructure in place within the community to measure this.


Development of a Community HUB:

  1. Single point of registry in the community.
  2. Common metrics across providers and agencies.
  3. Payment linked to measurable outcomes.


  1. No duplication
  2. More efficient and effective use of community resources
  3. Improvement in disparities – health and social
  4. Cost savings

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Implementing Pathways: Field Notes from the Southwest

Leah Steimel, MPH
Director, Office of Community Affairs
U. New Mexico Health Sciences Center
OCA logo<
UNM logo
Pathways logo

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Pathways: The Need in Bernalillo County

  • Health inequities prevalent
  • Fragmented services and silos
  • Frustration with status quo

Map of Bernalillo County

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Pathways: The Need in Bernalillo County

2006: Need for health navigators for uninsured identified.

2007: Pathways model introduced and working group formed.

2008: Collaborative planning to adapt model to local needs. Public funding negotiated and MOU signed.

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Planning and Funding: Strategic Advice

  • Facilitate/Coordinate/Deliberate/Give it time to come together
  • Processes need leadership from community stakeholders
  • Communication is key

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Finding Common Ground for Buy-In: Principles and Framework of Pathways Model

  • Versatile and universal: everyone sees their work in the model
  • Directly addresses social determinants of health
  • Leads to meaningful outcomes for vulnerable individual

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Making Pathways Work: The Critical Role of Navigators

  • Find most at risk community members
  • Build trust
  • Assess and identify problems
  • Guide clients through Pathways steps and confirm connections
  • Complete Pathways to achieve meaningful outcomes
  • Document information in database
  • Provide advice on systems barriers

Illustration shows the critical role of navigators

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Rita’s Story

Illustration shows one case study.

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Pathways at Work: Benefits for Clients

  • Addresses social needs and health needs
  • Empowerment to overcome barriers
  • Completion of program leads to meaningful results

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Data: Document Processes and Measure Results

  • Provides insight into real experiences of at risk population
  • Clarifies accomplishments and roadblocks
  • Opens up opportunities for shared problem-solving

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Takeaway Points

  • Planning: Take time and ensure broad participation
  • Navigators: Recognize they are critical actors in—and advisors to—successful program
  • Study results: Provide opportunity for working on systems change

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Get in Touch…

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Check Out the HUB Manual!

Now available at:

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Presentation Operator:
Greetings and welcome to “Connecting Those At Risk to Care: A Guide to Building a Community ‘HUB.’”  At this time all participants are in a listen-only mode.  A question and answer session will follow the formal presentation.  If anyone should require operator assistance during the call, please press *0 on your telephone keypad.  As a reminder this conference is being recorded.  It is now my pleasure to introduce your host Ms. Judi Consalvo for Westat Innovations.  Thank you, Ms. Consalvo, you may now begin. 

Judi Consalvo: Good afternoon.  On behalf of the Agency for Healthcare Research and Quality, I’d like to welcome you to our Web event entitled “Connecting Those At Risk to Care: A Guide to Building a Community “HUB.”  My name is Judi Consalvo, and I’m a program analyst in ARHQ’s Center for Outcomes and Evidence.  We are very excited about today’s topic and glad to see that you share our enthusiasm.  We’ve had over 800 registrants for this particular event, and we will be polling you in a few minutes to get a better feel for who has joined us today.  Since some of you may be new to ARHQ’s Healthcare Innovations Exchange, I’ll take just a minute to give you an overview before I introduce today’s moderator.  The Innovations Exchange aims to accelerate the development and adoptions of innovations in health care delivery.  It supports the agency’s mission to improve the safety, effectiveness, patient centeredness, timeliness, efficiency and equity of care, with a particular emphasis on reducing disparities in health care and health among racial, ethnic and socioeconomic groups.

The Innovations Exchange was launched in 2008. Today there are over 480 Innovations now on the site.  As you might expect, the Exchange is constantly in the process of innovating.  We are always actively expanding with new topics and ideas as we address the challenges of health care delivery.  We are always reaching out to our audience and inviting active participation.  We offer a range of opportunities for comment and discussion, including this Web event.  We also offer opportunities to learn and network with innovators, doctors and experts.  You will be hearing more about our learning network in just a few minutes. 

This Web event is part of a series of Web events to support you in developing and adopting innovations in healthcare delivery.  We invite you to take a look at our  materials from our most recent Web event on guided care nursing.  It can be found on your Web site at  We hope you will join us for future events that will be announced on the Health Care Innovations Exchange Web site.  Stay tuned for a new Web event in November.  We also welcome your thoughts on other topics we could address with you.  At the end of today’s event, you will be asked to complete a brief evaluation form.  Your comments will help us to plan future events that meet your needs.  You can also e-mail your comments and ideas to us at

While we don’t anticipate any technical problems, I’d like to give you a few tips in case you experience any.  First, no phone is necessary for this event.  You may just stream the audio over the Web through the speakers on your computer.  If you experience any difficulty with the sound coming through your computer speakers, please notify the VCall attendant via the questions window.  If you have any trouble with the slides or your connection to the Web event, try pressing F5 to refresh your screen.  We are recording this event so that anyone who couldn’t make it today or needs to leave the Web event early can listen to the recording or read the transcript.  You will be able to find links to a downloadable recording, the slides and a transcript on the ARHQ Health Care Innovations Exchange Web site in a few days.  In fact, if you’d like to download the slides for today’s presentations, you can find them through the link at the top of the screen.  You may submit questions at any time through the questions window as pictured in the screen shot.  We will be answering questions near the end of the Web event. 

Okay, so before we get started, I’d like to give our panelists a sense of who we have out in the audience today.  Please answer the polling you see now on your screen.  Would you describe yourself as a community health program director, a community care coordinator, a community health planner, a health care provider, a researcher or a policymaker?  If you just want to take time to fill that out, and we’ll wait a few minutes and we can give you the results.  Okay, so we see we have community health program director at 16% as well as community care coordinator. The largest numbers are health care providers at 29%, researchers are next at 22%, and policy makers and I guess that’s community health planner.  So this is a great broad audience.  We welcome all of you, and we hope you enjoy this.  Now we’ve designed this Web event to be useful to a broad spectrum of participants, so we appreciate all of your participation.  So we proudly present this Web event to launch a new publication now available on the ARHQ Innovations Exchange Web site, “Connecting Those At Risk to Care, A Guide to Building a Community ‘HUB,’” to promote a system of collaboration, accountability and improved outcomes.  This guide describes current problems in serving at risk populations and the implications of those problems.  It then lays out a step-by-step community-based process that interested organizations can use to improve the quality and coordination of health and social services.  This guide is highly relevant and useful.  As we know, the Affordable Care Act places a strong emphasis on delivering coordinated care at the community level.  Now, with that very brief introduction, I’d like to introduce Laura Brennan, our moderator for today’s Web event.  Laura is currently Community Development and Policy Director of PacificSource Health Plans, independent, not-for-profit community health plans.  She is also Executive Director of the PacificSource Charitable Foundation in Portland, Oregon.  Laura?

Laura Brennan: Thanks so much, Judi, and to each of you for taking the time to join us today.  We’re thrilled to be here, and this has been a long time coming, working for a while.  I’m going to provide a high level overview of the Community Care Coordination Learning Network or CCCLN, I’m going to talk a bit about the Pathways Model and a bit about the Pathways Community HUB Manual itself, and then I’ll turn it over to our other panelists, whom I’ll introduce in just a bit. 

Next slide please.  In 2008, oh back a slide, pardon me.  In 2008, the Agency for Healthcare Research and Quality convened 16 communities from different diverse parts of the United States to better understand and support care coordination in order to eliminate health disparities that exist too often among racial and ethnic minority communities, those who are low income and uninsured, the geographically isolated, and other vulnerable groups.  Given how health and social services are organized and coordinated and delivered at a local or a regional level, the learning network sought to bring together community health leaders who expressed interesting in implementing and those who are currently implementing care coordination initiatives to reduce and ultimately eliminate health disparities. 

Next slide please.  The CCCLN members not only are geographically diverse as we just saw, but also are diverse in the health issues they’re addressing, albeit they all have community care coordination in common.  As you can see the health, the psychological and social issues CCCLN members are addressing include things such as pregnancy, patients in medical homes, health insurance, behavioral health processes management, and much more.  Through the ARHQ learning network, the CCCLN convene to do basically three things.  We come together to, one, share information on our individual communities and care coordination initiatives to find, treat and measure the health outcomes of vulnerable people and populations. Two,  we benefit from each other’s experiences, both our successful and challenging experiences in improving the health of the most vulnerable in our communities; and three, we learn about strategies and techniques needed to implement an effective and efficient community care coordination model, specifically in this case known as Pathways. 

Next slide please.  The Pathways Model promotes and assures collaboration and coordination across the community or across a region of health and social service providers.  Some are known, and some say that these providers are often segregated or they’re not integrated or they’re not patient-centered or they—or we—are operating as our own silos.  The Pathways approach—really a huge part of it—is to help break down those silos and to organize the local health and human delivery system to make sure that we find, treat and measure the health of those at risk in our communities.  More specifically, in the Pathways Model, we aim to ensure that people in need are first identified and enrolled in programs they’re eligible for.  Secondly that the individuals we see are connected to evidence-based and meaningful services and, three, that these individuals’ health outcomes are measured and improved.  This three-pronged approach—find, treat and measure—is improving the health of vulnerable populations in our nation’s communities.  The CCCLN members, based on our experiences, find that in order for the Pathways care coordination model to truly be successful in terms of promoting health and controlling and containing costs, a community HUB infrastructure is needed. 

Next slide please.  Consequently, Mark Redding and I were charged with forming a work group in order to create a Pathways community HUB toolkit and to share the story and the work of our CCCLN members.  We took lessons learned from the members and created what we hope is a “how-to guide,” if you will, about how to build a local or regional infrastructure that ensures that those at risk are connected to efficient and effective care, which is related to the topic of health outcomes.  So what’s a HUB you may ask?  We’re here to learn about the HUB Manual, and here I am talking about community care coordination pathways, the elimination of health disparities.  But what’s this HUB thing?  Well, the HUB, the Pathways Community HUB is really the infrastructure that provides tools and strategies needed to ensure that at risk individuals are served in a timely and coordinated manner, and the HUB is there to ensure that a person and populations are connected to meaningful health and social services that produce those positive outcomes, and that duplication of efforts and duplications of services are eliminated.  So it’s about coordination and communication and built incentives.  The HUB increases the effectiveness of care coordination services across multiple programs, across multiple organizations in the community or region.  To accomplish its goals, the HUB provides centralized prophecies, centralized systems and resources that allow a systematic tracking of those being served, and then ties payment to milestones that improve the health and well-being of the client. 

Next slide please.  As indicated, the HUB serves as an important part of a regional infrastructure to support local agencies and payers or funders to effectively serve those at greatest risk.  The HUB brings together public and private community stakeholders, including health and social service providers, elected officials, businesses, and representatives of the at risk population being served. It brings these folks together to determine the local health needs and to create the appropriate support, the appropriate services and the right interventions most effective for directing those in need.  To accomplish this, the HUB serves as a centralized clearinghouse that registers the at risk individuals—if you will—and coordinates the care they’re receiving, making sure that biological, psychological and social needs are met.  It’s worth noting that the HUB and this manual are not about supporting any sole or single agency, but rather the HUB is designed and intended to strengthen and support the health of an entire community, especially those who are most at risk.  So safety net providers and hospitals and public health departments and private practitioners and businesses, insurers, philanthropists, and others will thrive and benefit from the concrete strategies we’re hoping that this HUB Manual and this model offer in order to build a local delivery system that’s effective, that’s efficient, that’s sustainable, and strategies to build a community or regional delivery system that are coordinated and one that promotes health and contains costs. 

Next slide please.  So to tell you more about the Pathways Model and the HUB, you’re going to hear from Doctors Mark and Sarah Redding. Mark and Sarah live and work in Mansfield, Ohio and are the champions of CHAP, the Community Health Access Project. They’re the co-developers of the Pathways Care Coordination Model and they are in large part the inspiration and input behind ARQH’s Community Care Coordination Learning Network, which is part of the AHRQ Innovations Exchange.  And you’re going to hear from Leah Steimel.

Next slide please.  And Leah is the Director of the University of New Mexico’s Health Sciences Center, Office of Community Affairs and also the Director of the HUB, Pathways to a Healthy Bernalillo County or the Albuquerque, New Mexico area.  So, to frame the remaining of the Webinar, first we’re going to learn more about the Pathways Model from Mark, then we’re going to hear more about the role and the development of the HUB itself from Sarah, and then Leah is going to share with us about her work implementing the Pathways Care Coordination Model and the HUB in Albuquerque.  Again, feel free to send in your questions, and we will address as many as possible at the end of the presentation, and with that, take it away Mark.

Mark Redding: In making this kind of a presentation it helps me to have kind of a grounding statement. My 11-year-old son has recently completed some research, and what he found was that when his dad helps him, explaining, working through language and arts-elated homework, his homework grade actually drops precipitously.  This has especially been noted when comparing to when his mom helps him work through it.  So, in a fairly kind and politically correct way, he has redirected my efforts to other assignments.  Our work with communities and our homework with communities has been substantially helped by the Agency for Health Research and Quality and their partners at Westat.  As we have worked directly with community members and individuals reaching out and trying to address barriers and connect individuals to care, ARHQ has effectively reached out to us. We have created a really vital, sixteen member learning network, capturing wisdom that comes—I must admit most of what’s presented in this—comes directly from people within the community who are living and breathing health disparities within their own families and their neighbors.  They’re collecting the tools, the strategies, the ways, the things that can come from a community, that can promote change.  I have been working on this for over 20 years, and today we’re seeing substantial progress.  Additional collaborators in this work include HRSA, Medicaid managed care, the Ohio Department of Health, National Institutes of Health, private foundations, our Ohio policymakers, and many others. 

Our central focus, I mean if I could, if we can, if we can pass this part to you, our central focus is to connect those at risk for basic care, prevention and treatment.  That should be the center of this work.  What we’ve seen as a great potential for reform is so simple that it’s easily missed.  Every evidence-based intervention has as part of its foundation what we almost see as a check box: if a person who needs it, receives it.  Interestingly, we’ve made great progress improving the interventions themselves from vaccines, prenatal care, diabetes management, caring education—we could list thousands—all proven to improve health and reduce costs.  If you’re a wealthy American, you’re benefiting from this, and if you’re poor, you’re not.  The terminology we use to work through this description includes care coordination, which we see as the part of the system that’s focused on engaging the people most at risk and ensuring they connect.  The individuals that work in this space—from the doctor’s office waiting room out to the forgotten urban housing complex or rural house trailer— this is a space that many of us don’t have experience with and don’t know, but is not easily traversed, especially for those in extreme poverty. 

The people doing this today— its existing infrastructure includes nurses, social workers, community health workers, and others, who are knocking on doors and reaching out beyond the doctors’ offices and hospital stretchers. 

We also describe and talk about in the manual the delivery system itself, which we see as an overarching structure that works across agencies and across individual case workers, ensuring that they are working together as a team that connects those at risk to care. So possibly the greatest evidence-based examples of care coordination and an effective delivery system come from the work of the CDC and Dr. D.A. Henderson. In their situation, they had the evidence-based intervention of the small pox vaccine, and their challenge was to deliver it across the globe to almost everyone within a very short period of time.  Obviously, a vaccine in some ways is much simpler than prenatal care or primary care or diabetes education. Yet what would our national health outcomes look like if at-risk people were actually getting basic health and preventive services?  It’s an exciting example, especially because Dr. Henderson’s work resulted in a global improvement in health.  I’ve got a couple of quotes from him that I think are important for this.  He says “the program necessarily had to function within existing health service structures and had to take advantage of available resources.  Rigid manuals of operation intuitively made little sense given the diverse nation of national health structures. So broad goals, provision, and flexibility in achieving them became the accepted modes.”  He went on to say, “I see these approaches as key steps in revolutionizing and revitalizing public health.  Implicit in these new approaches is the setting of measurable goals and a willingness to look at all alternative methods for achieving them”. 

Dr. Henderson’s call for simplicity is very apparent in our current health care system.  Some state Medicaid contracts, for example, can extend more than five feet in double-sided printed height.  Yet, critical review may not even reveal a specific request to assure that those at risk connect to care.  We can’t just point the finger at any one particular agency.  Especially Medicaid is in the center of trying to improve this within our own and other communities.  It is an across-the-system problem. 

Next slide and that should be 16 with a picture of Alaska, if you could just go back one, thank you.  How did Sarah and I get interested in this?  Well, we set out for Alaska as missionaries, and Alaska had everything we wanted related to being missionaries—poverty and unbelievable barriers. But Sarah’s research there found that the outcomes in Alaska—especially related to birth—were better than almost anywhere in the lower 48, and what Alaska had is very similar to what Dr. Henderson called for.  They had a very simple system in place, so that if you’re pregnant and you live in Antler, Alaska, someone’s going to be at your door ensuring that you connect to basic health and social services.  When Sarah and I moved on to Baltimore and later Ohio, we found it startling that we could actually see better connections to basic preventive and early treatment services in arctic Alaska than down the street from some of the United States’ most substantial medical centers. 

Next slide 17.  Interestingly, recent research that is referenced in the manual clearly shows that if you are an at-risk individual in the United States, you are less likely today than a decade ago to connect to basic prevention and early treatment services.  In fact, during a time in which the health care budget has nearly tripled, those at risk are less likely to connect to care.  A pastor, who has been a significant part of our network, summarized this by saying the least of these our brethren are the least likely to connect to preventive care.  And interestingly, the most likely to connect to an ambulance, because you can get one of those in just a few minutes and would be much more likely to connect to basic preventives, prevention, and health care in developing nations with half of our per capita health expense.  If 5% of the population represents more than 50% of the cost, and the greatest weight of our health disparities, why don’t we have a system, a strategic incentive in place that results in us tripping over serving them, our disparity could improve and our costs could go down and we believe that can be done.

What are some of the reasons why it’s not happening?  Why is the system inadvertently avoiding those most at risk?  Though in health care, and in social services, time is money, it comes down to a billable unit rate per service, case loads, number of patients seen per hour, all tied to time.  Juanita, who is one of the outreach workers here in Mansfield, tells us that the homeless 17-year-old with a 15-month-old baby, she’s also pregnant, and needs to get back to her GED program and get employed—it can take her 30 times more time than somebody else who is still 200% of poverty and eligible for Medicaid, but has reasonable health and transportation and support of family.  Most providers of care coordination and direct service will tell you that they simply can’t afford to serve more than a small percentage of those highly complex and socially disadvantaged patients.  Next slide please. 

What have the communities taught, and we should be on the two rings, yes.  From the client’s perspective, an individual with significant health and social issues needs to have both addressed at the same time.  How can we expect the young lady to go to prenatal care or the elder to go to diabetes care if they don’t have a place to live or they don’t have enough food?  Next slide please. 

Amazingly—and what the capacity within our system is—we have the evidence-based intervention.  For a moment, see them like packages, sitting on the shelf, they are ready to go.  Our problem is, if you’re an at risk or disadvantaged individual in our country, you’re not receiving them.  Next slide please. 

All we need—and this may be an oversimplification but obviously we’ve done a good job of making things more complicated—we need a simple system that makes sure that people get the packages and there are many private business models that we can use as examples.  Next slide please. 

A-Place is in many ways like a UPS delivery system of tickets. Its records essentially track, communicate, and report, that is, specifically to find that an at-risk pregnant mother has been identified, barriers overcome, and connection to care confirmed with a measurable outcome documented.  We did not see much success with this until dollars started to tie to these basic benchmarks.  Next slide please. 

Obviously the example we gave there was pregnancy, but there are pathways for many different health and social service issues and essentially based on the client’s assessment of health and social issue, their particular issues become a pathway, and for each issue, they are connected to the intervention that addresses it, whether it be housing, medical care, or other issues. 

The key challenge—and next slide please—is to take this approach of pathways where case workers are confirming and connecting individuals to care and being accountable for it and being paid, the agency is being paid based on basic bench marks, and watching that improve over time.  But even more important is to see that kind of structure extend over a region or a community, and that is where it becomes a little bit more complicated for me.  I can’t even operate the phone.  So I better turn this over to Sarah. 

Sarah Redding: Thank you, Mark, and after working together for over 25 years, I’m never sure what kind of introduction I’m going to get, so that was pretty benign.  Let’s turn to slide 24.  Mark presented the Pathways Model to you and a little history behind it.  But let me show you what our data actually looked like.  So slide 24 shows what happened within our agency, within CHAP, after we implemented the Pathways Model.  And you can see, we put the model in place around 2000, and we had a decrease in low birth weight for our enrolled members, and actually, the little yellow box shows the Healthy People 2010 goal of 5%, and we hit that in 2003 and have maintained between 4 and 6% since that time.  What this slide doesn’t show you though is that when we put the Pathways Model in place, we exited over 200 clients, because basically, we couldn’t assign them to a pathway. 

Next slide, what this slide shows is what happened when we took the Pathways Model to the entire community.  The black line is Richmond County, Ohio.  The red line is the State of Ohio, and these are data from the Ohio Department of Health statistics Web site.  If you want a lot of detail about this process, you can look on page 9 in the HUB Manual that you can now download. But what I want to point out is our story is different than every other community involved in this CCCLN.  No two communities are alike in this process, but there are basic steps that can be followed, and that is outlined on page 5 of the Manual.  What happened within our community, we had 7 agencies working on a community-wide pregnancy pathway and, you can see starting in 2005, we started to have a dramatic drop in the low birth weight rate for all members of our county.  That is when we started to offer incentives to reach out to the most at risk pregnant women that we could find.  The hypothesis is pretty simple: if you connect to those most at risk of a poor outcome in a population group and make sure they connect to care, then you would expect to see overall health improve at the population level.  Next slide please. 

It truly is a systems issue, and going back to some of the key points that Mark made earlier, we know a very small part of our population is using a very large amount of resources.  We also know it’s very hard to serve some of these folks, They take a lot of time to find and have many, many issues to resolve.  There is no difference in compensation whether you’re serving somebody with one issue or 20 and the connection to care is truly getting worse for all of us. Next slide.

From a client’s perspective and again, thanks to our community health workers who really taught us this, if there is a pregnant woman in our community, she may be facing multiple issues with multiple providers and agencies.  Sure, she needs health care for the pregnancy, but she may also need housing, she may need childcare, she may be in a domestically violent relationship, she may need mental health services.  We as insiders knowing the system would have a very hard time navigating, and who is measuring the system?  We measure our individual programs whether they be in an agency or a clinic or a hospital, but we don’t measure the overall community system.  That’s the reason why we need something like the community HUB.  Next slide please. 

I am going to try to show you visually kind of what I have tried to say in words because, for some like me, I see better in pictures.  This slide shows what happened when we tried to map out in our community where the bad outcomes were happening, and this was in the old days, and we had to take a big map and use push pins.  But basically, we pulled a bunch of birth certificates, and we mapped out where the low birth weight births were happening, and after a whole pack of band aids, we could see that we had some very hot spots in our community for poor outcomes.  What happens though, when you look at the county level data, this gets diluted so we weren’t really picking this up until we went to this level of detail.  Next slide please. 

When we went and looked at where all the services were going in our community, we found that we had agencies going to parts of our communities that had had no low birth weights in over four years, and this became a very important argument in convincing our leaders within our community to actually change how we contracted around providing services.  Next slide.

So getting to the meat of this, the community HUB.  The statement from the manual says that the HUB’s primary goal is to ensure the timely provision of appropriate high quality, cost effective, evidence-based services that will have a meaningful impact on those served.  The HUB is a point of central registration.  It’s the clearinghouse.  This is where everybody is registered in the community and assigned to a care coordinator.  A key point with the HUB is it doesn’t single out any certain agency or any certain program.  It just provides the metrics, the common measurement in our situation, the pathways that we can track how outcomes are happening across the community and that allows everyone to play equally, whether it be the school, the hospital, the health department, we are all measured in the same way.  The biggest outcome here is that we eliminate duplication.  We take the resources that we have within the community that are ever so limited now and make sure that they are used efficiently and effectively.  The HUB becomes the infrastructure, that missing piece that is tracking community care coordination across the entire community.  Next slide.

The big kind of aha moment—at least for me—is when we were working within our own community when we first started this with the community pregnancy pathway, and we had all 7 agencies using the same pathway, and trained everybody, and it was all going swimmingly well, when we looked at our data after a full year of service, and we had really only served 19 women who were living in those high risk areas.  So we went back to our local funders and said you know, we really need to change the way we do business here.  We need to make sure that we incentivize agencies to go after the women who really need the care, and we need to pay them appropriately for the time it’s going to take.  And you can see when we did that, when we actually changed how we contracted, the very next year, we served 146 women living in those hot spot areas.  We had no more money to do this.  We just laid out the expectations to the agencies and paid them for the extra work that they did.  This explains why we started to see the low birth weight improve starting in 2005.  We actually made the last important piece of the model connect.  We tied payment to the outcomes, and we listed that as the major expectation of the agencies and care coordinators reaching out to the community.  This slide also shows, in that little box to the right, that it takes time.  I mean, we had more outcomes produced farther into the year than at the very beginning.  It’s a big change for the way communities operate.  Next slide please. 

Partnerships are key.  In the middle of this slide are the care coordinators, and they truly are like the UPS workers Mark was talking about.  They deliver the packages.  But also, very important are the funders to the left because they pay for the packages, and they set the expectations and the payment for the outcomes, and to the right are all of the agencies or providers within the community who really need to work together as a team and get out of the silo-based mentality because if we’re going to change health and social outcomes, we need to do it as a team with the client at the center.  The HUB is the infrastructure over all of this measuring what is going on over time.  Next slide please.

To summarize the key points before I turn this over to Leah, the initial problem statement, you know if we really do want to serve those that are most at risk of poor health and social outcomes, we have to realize right now we don’t have the infrastructure in place to do that.  What we see as a solution for this is the development of the community HUB, and that creates a single point of registry in the community.  It provides common metrics and measurements for all providers and agencies to use, and it links the payment to measurable outcomes.  The results being, if we do this right, we will eliminate duplication.  We will take the community resources we have and use them more efficiently and effectively.  We will save money and, most importantly, we will start to see improvement in health and social disparities.  Now I would like to turn this over to Leah, who is actually going to talk about her experience in her community of taking this model and actually implementing it.  Leah?

Laura Brennan: And Leah, this is Laura the moderator.  Before you begin, just real quickly, we want to make sure we have time for questions and answers. So I know I think we said 11 minutes, if you could do it in 9 or 10, that’d be great, and if not then we’ll manage. Thank you.

Leah Steimel: All right.  Well, thank you very much Laura, and Sarah and Mark.  I am delighted to be part of this panel and on behalf of our HUB in Bernalillo County which is essentially very much the same as Albuquerque, New Mexico, the county has a little bit broader range than just the city, but largely it’s Albuquerque.  We have lots of people who are working on this project here in Bernalillo and on behalf of all of us, we would like to thank you for this opportunity.  Next slide. 

For years, many of us have been sitting together talking about what the issues are, where we were able to identify fairly significant inequities and how the health status of the people that live in our county looked, and as you can see here, it’s hard to see the details but we have some community data folks who work on things like looking at number of social and health determinants across the county and mapping those out so we can see where the poorest people live, and we have discovered that there is a 10-year difference in life expectancy for people who live in some parts of our city compared to others or parts of our county compared to others.  We’ve also, you know, been very frustrated by the way people are sort of forced to work in silos.  We can see the problem but we couldn’t get to it.  Next slide.

Early on, like around 2006, there were some advocates in the community and others were working in the field who had begun to coin the term of “community health navigator” as the need that would make a difference across our county.  That if we had people that were serving as navigators for uninsured and our very vulnerable folks in our county, that that might make a difference in getting them connected to the services they needed to become healthier.  It took us about three years to work through discussions and planning and you know intentional collaboration, securing some funding and then implementing a program which was based on the Pathways Model that Dr. Redding and his wife designed.  We have been implementing the program here in Bernalillo County now for one year.  Next slide.

Probably one of the biggest things we learned in looking back, we really appreciated the guidance that we got from many people across the county about the importance of having the people who are directly serving the most at risk at the table.  That’s probably the biggest lesson that we learned.  We took a lot of time and planning, went through a very deliberate facilitative process that brought a lot of people to the table, and really focused on getting the people who were serving very at risk folks to the table.  So community health workers, outreach workers, public health nurses, the kinds of people that Sarah was identifying as well.  This took some adjusting timelines, format for planning.  Those kinds of things needed to be adjusted so that we really could listen to the people who knew what the real world was like, and it took being very intentional and focused on being effective and communicating with one another.  Next slide.

Our community health navigator has a critical role in our program, and in the slide that you’ll see in a moment, there is a list of roles that this community health navigator plays.  A critical one, of course, is building trust.  Okay, I’m sorry, I jumped ahead to a slide.  So on this, what I wanted to point out was that in the Pathways Model, what was so eye opening for us working here in Bernalillo County was that everyone could see their work in this model and particularly the community health navigator, community health worker could see where they fit and what the direct benefit to their client was going to be.  That made a big difference in getting everybody to sort of buy-in and hang on to the process of designing our program.  When the outreach worker could see that the person that they’re serving actually is going to have a meaningful outcome out of this interaction.  That made all the difference.  Next slide. 

This is where I was talking about the role of the community health navigator.  They find the most at risk, and one of the most important things that they do is build trust.  It’s not easy.  You’re finding people that have had a lot of very bad experiences—maybe just coming out of jail, maybe living in a park, may be very ill but able to get to the services they need in order to become well.  So the navigator works to build trust with the client, and then as you can kind of see in this diagram, the relationship between the client and the navigator becomes very key and together they identify what would make a difference to this person in helping them become healthy or feel like they are healthier.  We have a program where we have an array of pathways to choose from, so the navigator and the client sit down and talk about what would make a difference to the client and they choose the pathway based on the client’s mood.  Next slide.

In this slide we have, to you it’s going to look a fairly complex diagram but it is a story, and it’s a diagram that we use on our Web site and that we used in building up to the program to help people really see how this can work.  So Rita is a client of Pathways, and she has come to one of our community organizations and has talked to a navigator and has told her story that she needs a job.  She needs stable housing for herself and her three children, and she needs a place to get regular health care because she has diabetes.  She knows she does, and she can’t keep up with the things she needs to do in order to feel like she has her diabetes under control.  So in this diagram, we are trying to show the step-by-step process that Rita can go through together with the navigator, and see how Rita can become a regular user in a health care clinic, and that can be her medical home in order for her to be able to manage her diabetes the way all of us would like to be able to do.  At the same time, the navigator is working on a path much like this with a step-by-step process for helping Rita find a job that’s going to work for her and also find housing.  Next slide. 

Laura Brennan: This is Laura, if you can wind it up, we want to make sure people can ask a few questions.

Leah Steimel:
Yeah, and I just have two more slides.  So…just to reiterate the benefits to a client like Rita, she can see that when she comes to the organization, the other needs that she has aren’t excluded because of the organization mission or the funding source for the organization that she’s come to.  So she can have attention to her needs that are going to make a difference to her, and she can see the steps that it’s going to take, and what a meaningful outcome means together with the navigator.  Finally, on the next slide, I talk about our data system, which is the registry that Sarah Redding referred to earlier.  We have a data system that the navigators find easy to use and that everybody around the table, the HUB, persons in the HUB like myself, the evaluators, the community advisory group, and the navigators can sit down together, look at what our program is telling us is happening, what kind of progress we’re making, what the systems issues are that our clients are consistently running into, in order to look for solutions together.  Thank you very much, Laura.  Let’s go to questions and answers. 

Laura Brennan:
Well, thank you, each of you and all of you on the phone.  I want, there are some themes I’m identifying in the questions that are coming in, and I thank you all who have submitted questions so far.  One of the things that people are asking about is the dollars and cents of this.  So, someone said we all know form, we all know form follows finance in health care, who is the payer in this, who controls the dollars, and that question has been asked by many, many.  I’m going to ask Sarah, would you like to address that question? 

Sarah Redding: Sure.  In our HUB it’s been a stepwise process, I mean to get the HUB up and going. Of course, we were kind of the pilot flight, so we did get some additional funding to some private foundations and sources, but the point where we are in the HUB now, we’re actually contracting with Medicaid managed care organizations that work in our area who definitely see the benefit of coming in, and contracting in the community with only one entity, like getting services all across the county for a whole variety of issues, so it becomes very attractive and not a hard sell at all, especially to funders like Medicaid managed care because they can directly see the benefit of this model.

Laura Brennan: Super.  Thank you very much.  Specifically, people also ask not just about the medical, but the social service piece.  Can you touch on that a little bit?  Sarah.

Sarah Redding: Oh I sure can.  What’s been kind of fascinating with this model even still growing in our own community, I’ve just brought on the Domestic Violence Shelter and the Homeless Shelter because both of those agencies have, certainly, have care coordinators and case managers, but they weren’t always thinking about the health issues or the bigger picture, so as our HUB is growing.  We’re actually bringing in all of the safety net providers that are a lot the times the social agencies in the community that can also use the connections to health care and other basic services. 

Laura Brennan: Terrific.  Thank you.  Another theme that I’m identifying in the questions is who owns or oversees the HUB?  Can you compare community health team or community care team, it says, communities served by patients that are medical homes and ambulatory care and the related community-based services, but I think what I’m noticing many people are asking, who is in charge of the HUB, and how do you figure out the second prongs, that would be, how you figure out the metrics?  Mark will you steal that please? 

Mark Redding: Certainly.  It is varied from different communities, but I think what we’re seeing is that ideally it’s an agency that is connected to all of the, both social service- and care coordination-related agencies as well as the medical providers.  It essentially has a neutral kind of standing, at best, and does not provide direct services themselves.  It does not require a huge staff, it can be a small staff with really more of a, if you go back to the UPS model, somebody who is looking over the community and making sure the services are going where they need to go and helping to facilitate the elimination of duplication and that people at risk connect the care.  And, like Sarah said, there is quite a diversity, since almost every health and social service line item in the state and federal budgets has care coordination.  It can be quite a diverse setup, different providers and folks interested in and at least coordinating if not directly funding through the HUB, at least coordinating their funding through the HUB to assure non duplication in risk populations. 

Laura Brennan: Well, I want to thank everybody again, and I want to pass this over to Judi because I know that Judi has a few things to say before we depart. 

Judi Consalvo: Thank you, Laura, and thank you all very much, and please be sure to check out the HUB Manual, which is available on the AHRQ Innovations Exchange Web site.  So we value your feedback and hope you can spend a few minutes completing the evaluation that’s about to appear on your screen.  You can also check us out at any time at  Thank you.

Operator: Ladies and gentlemen, this does conclude today’s conference.  You may disconnect your lines at this time, and we thank you all for your participation.  Have a wonderful day. 
Related AHRQ Publication
Connecting Those at Risk to Care: A Guide to Building a Community "HUB" To Promote a System of Collaboration, Accountability, and Improved Outcomes (HTML) (PDF) (Adobe Reader is required to view or print the PDF. Download a free copy hereExternal Web Site Policy)