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Franklin County Pathways
Community HUBAligning performance for results-based health
and social servicesQuarterly Learning Session – April 8, 2016
2
Session Objectives
Learning Session Objectives
WHYWhy do we need a Pathways Community HUB
in central Ohio?
WHAT What future value can it add?
HOWHow does a Pathways Community HUB
operate?
Why do we need a Pathways Community
HUB in central Ohio?
3
People in need face
complex and
interconnected
issues, often
requiring them to
seek help from
multiple sources
Health and social
service providers
recognize clients’
multiple needs and
often coordinate
referrals, but varying
approaches and
limited resources
affect results
Funders/payers
question whether
their dollars are
achieving the results
they seek or if
they’re paying for
something that
could have been
prevented
Our community
continues to have 1
in 5 people living
poverty, and 1 in 3
struggling to meet
basic needs
4
Why do we need a Pathways Community
HUB in central Ohio?
What future value can this model add?
5
What future value can this model add?
6
FIND PROVIDE MEASURE
How does a Pathways Community HUB
operate?
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HUB
• Administrative and information
technology infrastructure that
provides tools, standards, and
resources to operate model
• Provide data processing,
reporting, invoicing, and
collection tools
• Provide or arrange training for
community care coordinators
in Pathways Method and use
of Hub data system
• Support and assist care
coordination agencies in
quality improvement and
quality assurance activities
• Maintain all client data in
compliance with applicable
requirements of HIPAA,
HITECH, and other
regulations
Care Coordination Agencies (CCAs)
• Establish contract and
business associate agreement
with HUB
• Provide care coordination
services to clients using
community care coordinators
trained and supervised in
Pathways Method
• Perform mutually agreed upon
supervision, quality
improvement, and quality
assurance activities
• Ensure sufficient education
and training to community
care coordinators on HUB’s
data system, Pathways
Method, and community
resources
Community Care Coordinators (CCCs)
• Individuals trained, supported,
and responsible for delivering
care coordination services
• Employed by community
based agencies contracting
with HUB
• Work with client on care
coordination plan and monitor
progress to goals and
priorities using Pathways
method
• Provide client referrals and
resources to additional
services
• Maintain proper
documentation of services
provided and progress made
in implementation of care
coordination plan
Funders/Payers
• Public-private entities
establish contracts/
agreements with HUB to
support delivery of care
coordination services to
specific populations using
accountable payment
arrangements
• Contract terms structured
based on payments to care
coordination agencies for
qualifying activities and
outcomes
• Payments will directly support
care coordination activities
and be reinvested in support
of HUB operations
Patient with Diabetes
Increased patient show rates for appointments
Increase in Clinical Outcomes Measures
3/2015 A1C -8.1 6/15 A1C – 7.1 7/2015 A1C - 6
Reduction of barriers for social determinants of health to care for patients
Increased patient compliance in the management of their condition
9lb weight loss Medication
Adherence Better Nutrition
Increased access to resources for patients
How it works
FIND: Initial Checklist – Captures
Comprehensive Risk IssuesPROVIDE: Pathways identified and
initiated
MEASURE: Risk Factor Reduction
Care Coordinator
• 52 yr old, AA female• Medicaid• Food Svc. Employee• Diabetic: A1C-8.1
Risk Assessment Needs
• Eye Exam• Foot Exam• Depression• Furniture (was homeless)• Food Access/Nutrition
Education• Medication Education• Insurance Education
Medical Referral
Social Service
Education
Medical Referral
Social Service
Medical Referral
Eye Appointment
Podiatry Appointment
Nutrition –Fruits and Vegetables
Mental Health Appt.
Diabetes Education –Medication Adherence
Food Pantry
Furniture Bank
Education
Care Coordinator
Using Data
to Improve
Results and
Reduce
Duplication
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What are your questions?
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