The Better Health Pathways HUB and its standardized processes align funders, health care providers, and social service providers to deploy holistic approaches that coordinates care for at-risk populations with complex health and social needs.
How it Works: Community Health Workers (CHWs) serve as partners, advocates, and coaches for their clients, guiding them through a process to identify risks, assign them to pathways so solutions can be achieved, and remain available to support clients to completion of pathway objectives.
Clients are Cuyahoga County residents including individuals who are pregnant, infant, children and adults. Each risk is assessed and assigned to a pathway, such as needs for food, transportation, housing, and more, and the pathways are tracked through completion.
CHWs are employed by care coordination agencies that partner with the Pathways HUB to provide these services. The CHW's care coordination agency is reimbursed when clients complete required steps in the pathway process.
Core Features of the HUB
Pathways: Pathways are evidence-based protocols and checklists that standardize work, ensure accountability, and facilitate payer reimbursement for outcomes achieved. The pathways incorporate multiple functions to help address the wide variety of circumstances that at-risk individuals face.
Pathways HUB Coordination
This model provides a single point of contact for care coordination for individuals and families. Care coordinators understand all pathways through a common set of credentials required as certified Community Health Workers (CHWs). The HUB brings together CHWs across agencies for support, shared purpose and continued professional development.
Shared Referral Infrastructure
Care coordination agencies that contract with the Pathways HUB use a common data system that enables referrals and connections of clients to effective community resources, and to social services and healthcare providers to meet their complex needs. Data can be leveraged to inform strategic decisions and investments in effective upstream, system-level interventions.
Support from government, health care, payers and private philanthropy is needed to ensure that pathways coordination occurs for all at-risk populations with complex needs. Payment is made to care coordination agencies contracted with the HUB when pathways are completed, or at agreed-upon milestones for outcomes.
Return on Investment a study published in 2014 on a pathway for preventing low birthweights found a decrease from 13% to 6.19% over four years with the pathway intervention which resulted in overall savings of $3.36 in the first year of life and $5.59 in long-term savings for every dollar spent on the HUB.