Many individually modifiable risk factors hinge on changes in client behavior related to things like nutrition, education, parenting, or compliance with medical care. The Pathways Community HUB Manual is designed as a guide to help those interested in improving care coordination to individuals at highest risk for poor health outcomes. This approach identifies specific social and health needs—called pathways—and supports clients with prioritizing and addressing their needs. Pathways Community HUB Meeting. Community Health Action Teams (CHATs) consist of a provider, a nurse case manager, a mental health practitioner or social worker, and a community health worker. We continue to provide this service. • HUB Quality Assurance • Population Health Hot -spotting • Shared Learning • HUB Data Notes: • Standard reporting still in development • Soft launch, practical notes • Majority of clients from Coastal Community Action. Pathways Community HUB Pathways Community HUB represents a network of care coordination agencies focused on reaching those at greatest risk and addressing their identified risk factors. Pathways HUB. The Pathways Community HUB(PCH) model - The PCH model has more than 20 years of experience and research in efforts to engage communities in finding those at greatest risk and assuring they connect to evidence based social, medical The Pathways Community HUB Model is now utilized from infancy to adulthood to assure accountable outreach to at risk individuals, documenting reduced risk, improved outcomes and reduced cost. The Pathways Community HUB (HUB) model is a strategy to identify and address risk factors at the level of the individual, but can also impact population health through data collected. The R&E Hub aims to deliver tangible benefits and added value to the HealthPathways platform, the health systems and to the patient populations of individual members. 2201 South 19th Street, #101 Sarah and Mark Redding and a team of individuals working together over many years to support communities and community health workers (CHWs) in improving health and social equity. November 21, 2018. Objectives Understand the importance of community-based care coordination Understand “whole person” care coordination Describe the Pathways Community HUB approach The HUB is a nationally recognized solution. Pathways HUB staff coordinates and trains community health workers and other care coordinators, as well as tracks intervention results. Better Health Partnership Pathways HUB in Cleveland, OH, Community CarePort HUB in Olympia Washington, Community Connections in Northern Michigan, and Grow Healthy Together in San Antonio, TX all achieved some level of Certification. One of the six selected Medicaid Transformation Projects, the Pathways Community HUB is a care coordination model that uses community-based care coordinators (called Pathways Community Specialists) to bridge the connection between clinical and non-clinical support services (such as housing, education, or food.) What is the Pathways Community HUB Model? Through Health Homes, we help our most at-risk Pierce County residents connect to long-term, supportive care management. Tacoma, WA 98405 We convene organizations from the community to identify and prioritize community health needs. Our Pathways Community HUB Model is celebrating its second anniversary! Pathways HUB Community Care Coordination by Martinez Street Women's Center. Come back soon to learn more. 147 Pathways. The program brings together community providers, medical resources and social services to help ensure all Stark County babies celebrate their first birthdays. The content was developed by the Pathways Community HUB Certification Program. Our Care Coordinators work individually with clients to identify risk factors from all aspects of a client’s life. Calendar Our Care Continuum Network connects vulnerable and under-served populations to services and resources for whole-person health and community advocacy. The Pathways Community HUB model provides community-based and person-centered care coordination for vulnerable and traditionally under-served populations. By collaborating to share strengths and address challenges, we eliminate duplication and remove barriers across the spectrum of care and services. Pathways HUB. Toward that goal, some communities in the Buckeye State have implemented the Pathways Community HUB model to strengthen care coordination for individuals at highest risk of poor health outcomes. The Pathways Approach. The HUBs engage with care coordination agencies (e.g., local health departments, Head Start, housing authority and medical clinics) that Implementing a Pathways Community HUB in our region was a huge undertaking, but one that built on their successful track record with the Health Home program. Communities across Ohio have been working to strengthen care coordination. Mark and his wife Sarah developed the Pathways Community HUB model. December 1, 2020. Northwest Ohio Pathways HUB - Hospital Council of Northwest … The Kresge Foundation with help from the Georgia Health Policy Center and the Rockville Institute launched our HUB Certification initiative in 2012. Akron Summit Community Action, Inc. FAQ. The Pathways Community HUB will connect the healthcare system and social determinants of health partners to achieve the goal of improving population health in the NCACH region. Careers Pathways Community HUB @ Care Coordination Systems 2012-2018 Community Service provider Hospital/ Organization Client/ Patient/ Provider HealthBridge.care – Enhancing care with Community Resources and Partners Interoperability Community Resources and Engagement HB CHR. HealthPathways empowers clinicians with locally agreed information to make the right decisions, together with patients, at the point of care. Akron Summit Community Action, Inc. The Center for Health Affairs will host the Pathways Community HUB Meeting in order to deepen understanding of the HUB model. We sincerely appreciate the investment of our local community champions that have helped launch this evidence based program. We sincerely appreciate the investment of our local community champions that have helped launch this evidence based program. The work of CHWs involves reaching out to those at greatest risk and assuring medical, social and behavioral health risk factors are identified and addressed. This work is growing and involves more than 30 community HUBs that have completed or are working on Certification. The Pathways Community HUB Certification Program was founded in 2015 as the nation’s only certifying body for community care coordination HUBs. March 03, 2020 — After much consideration, the North Central Accountable Community of Health (NCACH) has decided to discontinue the contract held with Action Health Partners to implement the Pathways Community HUB. Significant improvements in patient management, quality of care, and cost containment are all important results you can achieve by utilizing Pathways … The Pathways HUB expanded in 2015 to address diabetes, heart disease and other chronic conditions in Lucas County through a three-year Partnerships to Improve Community Health grant from the Centers for Disease Control and Prevention. Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 We convene community-based and clinical organizations to provide healthcare and wraparound services to improve the livelihood of those in need. The This decision was largely impacted by the Washington State Health Care Authority’s (HCA) recent decision to no longer support the Pathways Community HUB […] Evidence-based community care coordination approach to connect at-risk individuals to care and services Risk factors are addressed through ‘Pathways’ Risk factors may include: Diagnosis mental health, chronic conditions Pregnancy status normal risk, high risk Health behaviors tobacco, alcohol use 13 Completed. The Pathways HUB Community Action has three initiatives currently in Summit County Pregnancy Pathways Initiative. This team works together to break down silos and increase communication to connect clients to tools and resources for improving quality of life. Communities across Ohio have been working to strengthen care coordination. The HUB Certification model provides the infrastructure to manage multiple sources of care coordination funding across the community network. Click here to see a full summary of the study. Mark works part time as a primary care pediatrician for Akron Children’s Hospital. She is the co-founder of the Pathways Community HUB Model along with her husband, Mark Redding, MD. To learn more about the HUB, please contact: Jenelle Hoseus, MBA Executive Director, Pathways HUB and Care Coordination Network Healthcare Collaborative of Greater Columbus 614-296-5807 jenelle @hcgc.org For every dollar spent on Community Hub activities for our members there was a savings of $2.36." When combined, these tools help communities in their initiatives to improve health equity and measure success of those initiatives. Brenda is a Doctorate of Professional Studies in Bioethics and Health Policy student in the Albany Medical College, Alden March Bioethics Institute and a graduate of the Georgetown (B.S., Psychology) and George Washington (Masters, Health Services Administration-M.H.S.A.) Average CHW Caseloads ~ 18%. HUB Certification is now led by PCHI, in partnership with the Georgia Health Policy Center (GHPC). The family hub model is an approach to the delivery of early help services centralised around a building, where a number of different services providing information and support to families, children and young people are based. There are 20 pathways to healthy living, such as health education, family planning, health insurance, housing, immunizations, and social service referral. The HUB provides data analysis, knowledge transfer, and logistical support to care coordination agencies. The HUB provides data analysis, knowledge transfer, and logistical support to care coordination agencies. The Model encompasses community network development guidance, incentives for community-based organization collaboration, client and family risk assessments, CHW training, Pathways risk-mitigation workflows to confirm that of outcomes are achieved, as well as billing and common reporting and benchmarks. Evidence-based community care coordination approach to connect at-risk individuals to care and services Risk factors are addressed through ‘Pathways’ Risk factors may include: Diagnosis mental health, chronic conditions Pregnancy status normal risk, high risk Health behaviors tobacco, alcohol use Local community health workers work closely with families to connect to social and medical services to remove barriers to health. Elevate Health has been designated by the Washington State Health Care Authority to lead care coordination organizations in the region, providing training and oversight to promote high quality, holistic care. This approach identifies specific social and health needs—called pathways—and supports clients with prioritizing and addressing their needs. The Pathways Community Hub model operates under the over-arching theme of improving patient … Mark has over 30 years of work and related experience in the development, support and evaluation of community health workers (CHWs) in providing community-based care coordination. Directors of the HUB and community leaders will gather to share their input and experience. The Pathways are the specific tools the HUB model uses to track an individual’s outcomes.17 A complete list of the Pathways Community HUB model’s approved Pathways can be found in the box. The Pathways are the specific tools the HUB model uses to track an individual’s outcomes.17 A complete list of the Pathways Community HUB model’s approved Pathways can be found in the box. To ensure quality and […] The Pathways Community HUB Institute The Premise Through their practice, they saw that individually modifiable risk factors (spanning medical, social and behavioral health needs), can be effectively identified and addressed by capitalizing on the strong, trusting relationships CHWs develop over time with the individuals and families they serve. Privacy Policy 7 PCHI provides invited care coordination workflow platform providers to complete Self Assessment Attestations about their ability to support the Pathway 2.0 HUB Model. March 03, 2020 — After much consideration, the North Central Accountable Community of Health (NCACH) has decided to discontinue the contract held with Action Health Partners to implement the Pathways Community HUB. We partner with community and clinical organizations who provide care coordination services to individuals with complex health needs. Initiatives. View more Community HUB Model The Community Health Access Project developed the Community HUB Model to connect at-risk individuals to health and social services and improve their health outcomes. The Pathways Community HUB Institute (PCHI) was founded by Drs. Sarah completed her specialty training in General Preventive Medicine at Johns Hopkins University. This manual is intended as a reference and not as a substitute for professional judgment. 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. Copyright © 2019 by Pathways Community HUB Institute. Pathways Community HUB Model Examined as Tool to Strengthen Care Coordination. We are very excited to announce the launch of the Pathways Community HUB in Grant County! This decision was largely impacted by the Washington State Health Care Authority’s (HCA) recent decision to no longer support the Pathways Community HUB […] Community Health Action Teams (CHATs) may consist of a provider, a nurse case manager, a mental health practitioner or social worker, and a community health worker. The HUB model is designed to transform communities through improving outcomes for those most at-risk. The R&E Hub aims to deliver tangible benefits and added value to the HealthPathways platform, the health systems and to the patient populations of individual members. 13 Completed. 6 Fully trained coordinators @ 5 CCAs. Co-Founder, Director of Research, Quality. The HUB is an evidence-based model of community care coordination that focuses on addressing social determinants of health (SDOH) risk factors in food insecure or other high-risk individuals. Pathways Community HUB CDHD SHIP Team Central Health Collaborative December 5, 2017 This work has included strategies to tie financing to confirmed reductions in risk. Evidence and Related Publications https://pchi-hub.com/publications Journal of Mat and Child Health 60% reduction in low birth weight and %500 return on CHWs, who regularly visit clients in their homes, are in a unique role to be able not only to support coordination of care, but to also coach and support individuals to learn new skills, get access to needed services, and make vital behavioral changes to improve their health and social outcomes. Toward that goal, some communities in the Buckeye State have implemented the Pathways Community HUB model to strengthen care coordination for individuals at highest risk of poor health outcomes. PCHI has received funding and support from AHRQ to establish a program of national Community HUB Certification. People living with complex medical and mental health conditions often struggle to address their basic needs. Pathways Community HUB Manual is intended to assist service providers and community organizations in creating a HUB to coordinate delivery of health care and social services. Pathways HUB is replicating an evidenced-based … 6 Fully trained coordinators @ 5 CCAs. Mark works in support of the model’s national certification at PCHI as well as within research at Akron Children’s Hospital Risk Reduction Research Initiative. Leveraging their more than 30 years of experience in community health, the Reddings and the PCHI team developed the HUB model, a financially accountable, outcomes-payment care model that is based on confirmed risk mitigation. Pathways HUB is replicating an evidenced-based model Directors of the HUB and community leaders will gather to share their input and experience. ask@elevatehealth.org, Resources 253-302-5508 The PCHI is a nonprofit certification organization that serves a broad range of community care coordination service networks. By addressing social determinants of health and supporting patient navigation of health systems, we empower individuals facing complex health needs with tools and resources for improved quality of life. There are 20 pathways to healthy living, including adult education, family planning, health insurance, housing, immunizations, and social service referral. The Pathways Community HUB Certification Program (PCHCP) under PCHI was created to provide standards for communities to follow to achieve model fidelity and program effectiveness. This team works together to provide wrap-around services to reduce issues and access to care. Stark County THRIVE Pathways Hub is an initiative coordinated through the Canton City Health Department to help prevent infant mortality and reduce disparities in birth outcomes. This approach identifies specific social and health needs—called pathways—and … What is the Pathways Community HUB Model? The Winona Community HUB provides the structure to ensure that Winona’s most vulnerable families’ complex needs are addressed in an equitable, unduplicated and meaningful way. The Pathways Community HUB model provides community-based and person-centered care coordination for vulnerable and traditionally under-served populations. The Ohio Chapter, American Academy of Pediatrics is collaborating with the Pathways Community HUB locations in Ohio to provide education and expertise in several topic areas, including: Immunizations; Obesity Prevention; Parenting & Discipline; Safe Sleep; This collaboration includes providing resources and trainings to the certified community health workers working with the HUBs. Community health workers help pregnant moms navigate and coordinate the systems and resources throughout the pregnancy to help her have a healthy pregnancy, delivery, and baby. HUB-related support from technology platform providers. • HUB Quality Assurance • Population Health Hot -spotting • Shared Learning • HUB Data Notes: • Standard reporting still in development • Soft launch, practical notes • Majority of clients from Coastal Community Action. 28 Clients. Improving Health Outcomes Pathways Community HUB represents a network of care coordination agencies focused on reaching those at greatest risk and addressing their identified risk factors. pathways community hub Northpointe at Vistancia starts construction on amenity site Northpointe at Vistancia, located within the 7,100-acre Vistancia master plan in north Peoria, has broken ground on a 10-acre amenity site that includes a 5,300-square-foot recreation center called The Sovita Club, centrally located in the first phase of Vistancia’s finale community. The Pathways Community HUB is an evidence-based model for care coordination leveraging community health workers. The Care Coordinators … The Pathways Community HUB model provides community-based and person-centered care coordination for vulnerable and traditionally under-served populations. The model uses 20 Pathways that address the social determinants of health to improve health outcomes. Universities. Pathways Community HUB Manual A Guide to Identify and Address Risk Factors, Reduce Costs, and Improve Outcomes. 1.24 miles away, 801 N. Olive St, San Antonio, TX, 78202, D2 COVID-19 Notice. The HealthPathways Research and Evaluation Hub (R&E Hub) has been established to encourage, assist and facilitate R&E in the HealthPathways Community. In partnership with The Bexar County Health Collaborative, we work with community families to identify and address their needs. Community health workers are at the front line serving as a liaison between health, wellness and social services in a community. With published evidence of both outcome improvement and cost savings, this approach and its national Certification is officially recognized by both payers and policy makers focused on pay for outcomes. We celebrated four new HUBs joining the PCH Community. Stark County THRIVE Pathways Hub is an initiative coordinated through the Canton City Health Department to help prevent infant mortality and reduce disparities in birth outcomes. Media & Press Pathways Community HUB Model Sarah Redding, MD, MPH Executive Director, Pathways Community HUB Institute. Pathways Family Hub. Elevate Health’s Pathways Community HUB (HUB) is now recognized and certified by the Pathways Community HUB Institute (PCHI) with a Level-I designation making it the first of its kind to be certified in Washington state. We are providing training and oversight to support the Health Homes program. They are a key workforce to facilitate client access to services by possessing a deep understanding of the communities they serve. This approach identifies specific social and health needs—called pathways—and supports clients with prioritizing and addressing their needs. Pathways Community HUB Model Examined as Tool to Strengthen Care Coordination. Community CarePort (CPAA’s Pathways HUB) provides “Care Traffic Control” to break down silos, coordinate care, and improve health. Certification ensures: Your HUB is able to maintain fidelity to the evidence-based Pathways 2.0 HUB Model – a key requirement when building relationships and negotiating with MCOs. The Pathways Community Hub seeks to empower individuals in Eastern Oregon by removing social barriers that make it difficult for them to focus on their own health. How the Pathways Community HUB is changing lives in Pierce County. The Center for Health Affairs will host the Pathways Community HUB Meeting in order to deepen understanding of the HUB model. Description The Pathways Community Hub, managed by Northeast Oregon Network (NEON), utilizes trained Community Health Workers (CHWs) to help at-risk patients navigate health and social services resources in the Oregon counties of Union, Baker, Wallowa, Umatilla, and Malheur.. The pilot launched in Moses Lake in October 2018, and we conducted a rapid-cycle evaluation to learn about successes and challenges, including barriers that delayed expansion. PCHI does not endorse any technology platform providers, but helps emerging HUBs identify possible TPPs. There are 11 prerequisites that must be met before a new HUB can move forward with the certification process. The HealthPathways Research and Evaluation Hub (R&E Hub) has been established to encourage, assist and facilitate R&E in the HealthPathways Community. People living with complex medical and mental health conditions often struggle to address their basic needs. Rural Project Summary: NEON Pathways Community Hub - Rural … SWACH is working with regional partners on a Pathways HUB. We are proud and excited to reach this milestone, and also inspired by the health care workers and teams we’ve collaborated with in the last two years whose contributions have helped to make the Pathways Community HUB a success. Average CHW Caseloads ~ 18%. Pathways Community HUB Pathways Community HUB represents a network of care coordination agencies focused on reaching those at greatest risk and addressing their identified risk factors. The program brings together community providers, medical resources and social services to help ensure all Stark County babies celebrate their first birthdays. PCHI does not endorse any technology platform providers, but helps emerging HUBs identify possible TPPs. The program trains and supports Community Health Workers (CHWs) who can connect Community Members with resources such as financial assistance, food access, housing, transportation, medical referrals, smoking cessation, and a … Elevate Health is designated by the Washington State Health Care Authority as a Health Homes lead organization. She is a seasoned health professional with more than 30 years of experience in the health services industry and is recognized as a thought leader, author, advocate and health strategist. The Pathways Community HUB Model offers hospitals a wide range of benefits related to meeting the needs of at-risk patients more easily and efficiently. Pathways Community HUB Meeting. The Pathways HUB involves the collaboration of all community resources to improve the health of individuals, especially those in vulnerable populations, by reducing both medical and social barriers to care, like employment, housing, and transportation. The Pathways model centers on regional HUBs, which act as the infrastructure for care coordination and referrals, connecting community members to the right services at the right time. Pathways Family Hub. The HUBs engage with care coordination agencies (e.g., local health departments, Head Start, housing authority and medical clinics) that It is done in partnership with many community stakeholders and with the support of various funding agencies. The Pathways Community HUB 2.0 Model helps communities work together to support their vulnerable populations. As a result, they often revolve in and out of emergency rooms. We are excited about the growing coordinated network of community agencies in our community focused on culturally connected evidence based service. The Pathways Community HUB model is designed to help address this challenge. As a result, they often revolve in and out of emergency rooms. Pathways Community HUB Model Sarah Redding, MD, MPH Executive Director, Pathways Community HUB Institute. Brenda is the Founder & Chief Executive Officer of Leath & Associates, Inc., and  a former Senior Study Director and Director of the Center on Health Disparities & Health Equity Research at Westat. The Pathways Community HUB model provides community-based and person-centered care coordination for vulnerable and traditionally under-served populations. 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