pathways and the hub 20150604

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CHW

Leading the Way in Delivering Better Community Health

Pathways and the HUB

“Typical” Family at Risk

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 ?

Current Community Care Coordination

HHS MEDICAID MANAGEDCARE

EARLY CHILDHOOD

CHILD PROTECTIVE SERVICES

HEALTH PLAN

Marisol Angelina Mrs. Garcia

Multiple care coordinators involved –limited communication

Social Determinants of Health

Poor Infant Mortality Rate

Social Determinants

of Health

Occupation

Education

Culture

Socioeconomic Status/Income

Neighborhood Race/Ethnicity

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Reducing Risk for Communities

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Engagement of at risk 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

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Find

Do you need a 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

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Treat - Pathways

Measure

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Step 3: Track and Measure Progress

Name Medical Home

Pregnancy Social Service

CHW A 5 2 10

CHW B 1 3 4

CHW C 9 15 18

Site MedicalHome

Pregnancy SocialService

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…

Dramatic Pathways Results

6.1

13.0

0

2

4

6

8

10

12

14

16

18

% of Low

Birth Weight B

irths

Pathways Intervention

Achieved through focus on social risk factors and organized care coordination in Pathways Community HUB

ControlGroup

Maternal and Child Health Journal

Maternal and Child Health JournalISSN 1092-7875Matern Child Health JDOI 10.1007/s10995-014-1554-4

Leading the Way in Delivering Better Community Heath

PREGNANT CLIENT

Click to edit 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

LBW in Richland County

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7

7.5

8

8.5

9

9.5

10

2005 2006 2007 2008

Perc

ent o

f LB

W B

irths

Low Birth Weight Rates in Ohio and Richland County: 2005-2008

RichlandOhio

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

13.4 13.2

9.5 9.5

0

2

4

6

8

10

12

14

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Ohio 2013 LucasCounty

2013

Pathways2013

Pathways2014

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-partumappointment within 90 days

Medicaid Costs: PER MEMBER 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: Multiplechronicdisease

Distinctions between Pathways & HUB

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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

One Care Coordinator for the Entire Family

Marisol

Angelina

Mrs. Garcia

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• 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

HUB

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HHSHousingAAA

Medicare/MedicaidManaged Care

State AgenciesCounty Departments

Private Health PlansFoundations

ClinicsFQHCsHospitalsPhysicians

One Care Coordinator for the Entire Family

Pathways Mobile

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Real-time Pathways and SDOH information from the community

Pathways HUB Connect

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HUB Connect enables organized and efficient community

care coordination.

Health

Behavioral Health

Social

Patient Activation

Family & Personal Health Management

Financial

Pathways RiskQtm

RiskQ for Hospital Readmission

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National Certification

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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

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Standard Billing CodesNormal

RiskHigh Risk

Modifier

ChecklistsInitial Pregnancy Checklist

Completed one time at Member enrollment, 1st

trimester engagementG9001 G9003 R1

Completed one time at Member enrollment, 2nd


Completed one time at Member enrollment, 3rd


Pregnancy Checklist

Completed at each face-to-face encounter with Member

G9005 G9010 R

PathwaysBehavioral Health Kept three scheduled behavioral health appointments G9002 G9009 RB

Education Educational module delivered. G9002 G9009 REFamily Planning LARC (long-acting, reversible) or permanent method G9002 G9009 G1

Family Planning All other family planning methods G9002 G9009 G2Housing Residing in affordable & suitable housing for 2

months.G9002 G9009 RI

Pathways Community HUB Model

• 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

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Endorsers of the Pathways Community HUB Model

The CMS Innovation Center

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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.

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CHW

Leading the Way in 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

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PREGNANT CLIENT

Leading the Way in Delivering Better Community Health

708-906-3057

75 East Market StreetAkron, Ohio 44308

[email protected]@ccspathways.com

Carecoordinationsystems.com

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pathways and the hub 20150604

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