Downloaded 13 times
Pathways and the HUB 20150604
- 1. 1 CHW Leading the Wayin Delivering Better Community Health Pathways and the HUB
- 2. “Typical” Family atRisk Marisol, 21 Angelina, 16 months Mrs. Garcia, 52 • Needs medical home • Behind on imms. • Behind on well visits • Developmental concerns ? • Pregnant • Lost job • No housing • No transportation • Depressed ? • Diabetic • Lives in 1 bedroom apt. • Limited income, works 32 hours • Financial stressors ?
- 3. Current Community CareCoordination HHS MEDICAID MANAGED CARE EARLY CHILDHOOD CHILD PROTECTIVE SERVICES HEALTH PLAN Marisol Angelina Mrs. Garcia Multiple care coordinators involved – limited communication
- 4.
- 5. Social Determinants ofHealth Poor Infant Mortality Rate Social Determinants of Health Occupation Education Culture Socioeconomic Status/Income Neighborhood Race/Ethnicity
- 6. 6 Reducing Risk forCommunities
- 7. 7 Engagement of atrisk client Collect information – Initial Checklist Assign Pathways Track/Measure Results (Connections to Care) By: Care Coordinator, Agency, Region Find. Treat. Measure. Step 1: Find Step 2: Treat Step 3: Measure
- 8. 8 Find Do you needa primary medical provider? Do you need health Insurance? Do you use tobacco products? Do you need food or clothing? Step 1: Engage at-risk clients with checklists. Example Checklists • Initial Adult • Adult • Initial Pregnancy • Pregnancy • Initial Pediatric • Pediatric Use checklist answers to identify Pathways to follow
- 9.
- 10. Measure 10 Step 3: Trackand Measure Progress Name Medical Home Pregnancy Social Service CHW A 5 2 10 CHW B 1 3 4 CHW C 9 15 18 Site Medical Home Pregnancy Social Service Agency A 50 25 22 Agency B 64 17 35 Agency C 40 32 19 By Community Care Coordinator By Agency Example Tracking Filters • Care Coordinator • Agency • HUB • Community • Region • Etc…
- 11. Dramatic Pathways Results 6.1 13.0 0 2 4 6 8 10 12 14 16 18 % of Low Birth Weight Births Pathways Intervention Achieved through focus on social risk factors and organized care coordination in Pathways Community HUB Control Group Maternal and Child Health Journal Maternal and ChildHealth Journal ISSN 1092-7875 Matern Child Health J DOI 10.1007/s10995-014-1554-4 Leading the Way in Delivering Better Community Heath
- 12. PREGNANT CLIENT Click toedit Master text styles •Second level • Third level • Fourth level • Fifth level Regional Organization and Tracking of Care Coordination AGENCY AGENCY AGENCY AGENCY CARE COORDINATION AGENCIES COMMUNITY HUB • Demographic Intake • Initial Checklist -- assign Pathways • Regular home visits – Checklists and Pathways completed • Discharge when Pathways completed (no issues) CLIENT CARE COORDINATOR
- 13. LBW in RichlandCounty 13 7 7.5 8 8.5 9 9.5 10 2005 2006 2007 2008 PercentofLBWBirths Low Birth Weight Rates in Ohio and Richland County: 2005-2008 Richland Ohio
- 14. Infant Mortality –Richland County 14 0 2 4 6 8 10 12 14 2007-2009 2010-2012 Richland County Infant Mortality Rate 2007-2009 and 2010–2012 (3 year trend data) Richland County White Black 2007 2008 2009 2010 2011 2012 Infant Deaths Total 15 6 14 15 14 6 White Deaths 11 6 12 13 13 5 Black Deaths 4 0 2 2 1 1 Births, Total** 1,606 1,523 1,517 1,339 1,353 1,410 White Births 1,436 1,365 1,353 1,199 1,220 1,260 Black Births 170 158 164 140 133 150
- 15. 13.4 13.2 9.5 9.5 0 2 4 6 8 10 12 14 16 Ohio2013 Lucas County 2013 Pathways 2013 Pathways 2014 Lucas County African American Low Birth Weight Rates 79% 74% 80% 10 20 30 40 50 60 70 80 2012 2013 2014 Percentage of NW Ohio Pathways Clients Attending Post-Partum Appointment 2012-2014 In 2013, 63% of women on Medicaid attended post-partum appointment within 90 days
- 16. Medicaid Costs: PERMEMBER PER MONTH B4-B1: 6 month periods before the beginning of MPBH (Jan 2011 – Dec 2012) T1-T3: 6 month periods since MPBH services began (Jan 2013 – June 2014) : indicates cohort enrollment into MPBH $0 $400 $800 $1,200 $1,600 B4 B3 B2 B1 T1 T2 T3 Cohort 1 Cohort 2 Ref: Super- utilizers Ref: Multiple chronic disease
- 17. Distinctions between Pathways& HUB 17 Pathways Care coordination facilitation tool Patient-centered Identify patient risks Social and traditional health issues identified Actionable & accountable Measured outcomes Trained & quality assurance to achieve results Payments for measured Pathway outcomes Community HUB Tracks Pathways (outcomes) across agencies Eliminate duplication Streamline referrals Provide infrastructure for community-based care coordination Involve braided funding – Pathways can be purchased by different funders Invoicing system
- 18. One Care Coordinatorfor the Entire Family Marisol Angelina Mrs. Garcia 18 • Medical Home PW • Immunization Referral PW • Medical Referral PW • Developmental Screening PW • Pregnancy PW • Employment PW • Housing PW • Medical Referral PW • Social Service Referral PW • Education PW – prenatal, parenting • Medical Referral PW – primary & specialty • Housing PW • Social Service Referral PW • Education PW - diabetes
- 19. HUB 19 HHS Housing AAA Medicare/ Medicaid Managed Care State Agencies CountyDepartments Private Health Plans Foundations Clinics FQHCs Hospitals Physicians One Care Coordinator for the Entire Family
- 20. Pathways Mobile 20 Real-time Pathways andSDOH information from the community
- 21. Pathways HUB Connect 21 HUBConnect enables organized and efficient community care coordination.
- 22. Health Behavioral Health Social Patient Activation Family& Personal Health Management Financial Pathways RiskQtm
- 23. RiskQ for HospitalReadmission 23
- 24.
- 25. 25 20 Core Pathways •Adult Education • Employment • Health Insurance • Housing • Medical Home • Medical Referral • Medication Assessment • Medication Management • Smoking Cessation • Social Service Referral • Behavioral Referral • Developmental Screening • Developmental Referral • Education • Family Planning • Immunization Screening • Immunization Referral • Lead Screening • Pregnancy • Postpartum
- 26. 26 Standard Billing Codes Normal Risk High Risk Modifier Checklists InitialPregnancy Checklist Completed one time at Member enrollment, 1st trimester engagement G9001 G9003 R1 Completed one time at Member enrollment, 2nd trimester engagement G9001 G9003 R2 Completed one time at Member enrollment, 3rd trimester engagement G9001 G9003 R3 Pregnancy Checklist Completed at each face-to-face encounter with Member G9005 G9010 R Pathways Behavioral Health Kept three scheduled behavioral health appointments G9002 G9009 RB Education Educational module delivered. G9002 G9009 RE Family Planning LARC (long-acting, reversible) or permanent method G9002 G9009 G1 Family Planning All other family planning methods G9002 G9009 G2 Housing Residing in affordable & suitable housing for 2 months. G9002 G9009 RI
- 27. Pathways Community HUBModel • Removes “silos” and fragmentation • Uses existing community resources efficiently and effectively • Focuses on common metrics to identify & track risks (risk reduction) • Holistic community care coordination – one care coordinator • Pays for outcomes – sustainable • Owned by the community 27
- 28. Endorsers of thePathways Community HUB Model The CMS Innovation Center
- 29. 29 Care Coordination Systems Founded to support and enhance the national certification initiative for Pathways Community HUBs with leading-edge systems, training, and best business practices to sustainability. Rapidly implement nationally certified Pathways Community HUBs through public/private partnerships with states and communities. Bridge information and referrals between the community and clinics, hospitals, physicians, insurers, and states. Use low cost/high-performance/rapid deployment/mobile first technologies as tools to efficiently empower community care coordination and HUBs. A “Good-Co”, socially responsible - reinvest the majority of profits in HUBs and HUB communities/projects, after reasonable investor returns.
- 30. 30 CHW Leading the Wayin Delivering Better Community Heath Care Coordination Systems Certified Pathways HUB Pathways RiskQ Pathways HUB Connect & Pathways Community CHW & Pathways Training Pathways CCS provides the Pathways Community HUB solution - including the necessary comprehensive services and systems - that can lead to HUB certification. – Pathways – Training – Pathways mobile and HIPAA software – Integrated patient portal – Customizable systems – HUB operations advisory – Risk Scoring and stratification
- 31. 31 PREGNANT CLIENT Leading the Way in Delivering Better Community Health 708-906-3057 75 EastMarket Street Akron, Ohio 44308 [email protected] [email protected] Carecoordinationsystems.com 31