Pathways and the HUB 20180710...3 Pathways Care coordination facilitation tools Patient-centered Identify patient risks Social and traditional health issues identified Actionable &

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CHW

Leading the Way in Delivering Better Community Health

Pathways and the HUB

Recognition for the Pathways Community HUB

The CMS Innovation Center

@ Care Coordination Systems 2012-2018

Pathways…

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Pathways Care coordination facilitation tools 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

@ Care Coordination Systems 2018

Pathways…


Evidence‐based and published model

Identify and reduce social risks to health

Produce measurable outcomes for quality improvement and research

Provide for continuity of care at lower cost

Improve quality of care

Lower cost of care through risk reduction

Provide Community‐Based Intensive Care Coordination for High Risk Members

Reduce isolation

Increase patient engagement through coordinated community‐based care

Identify and Reduce Hospital Readmission

Identify and Reduce unnecessary ER/ED utilization

Reduce Skilled Nursing Facility Usage

Reduce health disparity & inequities

Reduce low weight birth rates and pre‐term births

Reduce infant mortality

Applicable to Chronic Conditions Applicable to Maternal Health Applicable to Behavioral Health Applicable to Seniors and Pediatrics Applicable to Opioid Use Disorder Applicable to Substance Use Disorder

Additional Pathways Uses


Document for Transitional Care Management Revenue

Document for Chronic Care Management Revenue

Integrated with multi‐model Community Health Record platform

Connected with EHRs and Health Information Exchanges

Cited as suggested model for CMS Innovation grants

Measured outcomes produce invoicing transactions for sustainability

Recognized for innovation and results by leading healthcare organizations

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Reducing Risk for Communities


7@ Care Coordination Systems 2018

Social Influencers of Health

Clinical Measures

Social Influencers of

HealthOccupation

Education

Culture

Socioeconomic Status/Income

Neighborhood Race/Ethnicity


“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


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


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


“Care Traffic Control”

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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 Weigh

t Births

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

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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


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


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Standardized 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


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National Certification


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

23@ Care Coordination Systems 2012-2018


CHRCommunity Health Record

Pathways HUB Connect

Creates Community-Clinical Linkagesthrough Care Coordination

Pathways Mobile

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Real-time Pathways and SDOH information from the community



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HUB Connect enables organized and efficient community

care coordination.





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Information and Reporting


Access Real-time Member Information


Pathways Risk Scorecard Report

With Client, Family and Household Aggregation Options

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Integration with Care Delivery

Referral to HUB form

Care Team Dashboard

Health Information Exchange

Direct Messaging

API library• Bi-directional• Documented

ACH / Pathways

HUB

Community Agency

Community Care

Coordinator

Patient Care Team

ProviderClinic

Care Managers

Completing the Care Team Loop


RiskQ for Hospital Readmission


Public, Organization and HUB client‐facing site for Community Referrals

HealthBridge.care - Community Resources & Referrals


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HealthBridge.care - Community Resources & Referrals


HealthBridge

Hospitals, Providers &

Organizations

Pathways Community

Hub

Community

Multi-directional referrals and conversationsHospitals, Providers and OrganizationsPatients/Members/Clients/PublicCommunity-based OrganizationsCare Coordination

Integrated with Pathways (evidence-based model)

Secure and HIPAA-compliant

Also with Chronic Care Management and Transitional Care ManagementHealth Engagement TeamHealth Homes

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Referrals – Conversations


Health Bridge

Client / Public

Hospitals, Providers and Organizations

Community-based

Organization

Pathways HUB

Care Coordinator


HealthBridge Conversation Videos

The first video has John Exampleton, a HUB client, at the public facing website self‐referring with a community‐based organization (CBO). The care coordinator is kept up to date in the Pathways.

https://www.youtube.com/watch?v=AnLStiJryNI

The second video has the care coordinator making the referral to the CBO on behalf of John Exampleton, HUB client. The conversation is tracked in Pathways. John Exampleton has access to the schedule and conversation at the HealthBridge.care site.

https://www.youtube.com/watch?v=Fv3G4nj7ku0

https://www.HealthBridge.care

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Integration with Care Delivery

ACH / Pathways

HUB

Community Agency

Community Care

Coordinator

Patient Care Team

ProviderClinic

Care Managers

Pathways Community HUB


Community Service provider

Hospital/ Organization

Client/ Patient/Provider

HealthBridge.care – Enhancing care with Community Resources and

Partners

Interoperability

Community Resources and Engagement

HB

CHR

Health

Behavioral Health

Social

Patient Activation

Family & Personal Health Management

Financial

Pathways RiskQtm




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Standard Billing CodesNormal

RiskHigh Risk

Modifier

ChecklistsInitial Pregnancy Checklist

Completed one time at Member enrollment, 1st


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


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CHW

Leading the Way in Delivering Better Community Heath

Care Coordination Systems

Certified Pathways Community HUB

Pathways RiskQ &Pathways Insight Research

Community Health Record Pathways HUB Connect

HealthBridge.care & Pathways Community

Community Health Worker, Supervisory, HUB Staff & Pathways Training

PathwaysChronic Care Management

Transitional Care Management

Health Engagement TeamHealth Homes

The comprehensive solution provider for turn-key Pathways Community HUBs

– Pathways (evidence-based)

– Training– Pathways mobile– HIPAA-compliant, Secure– Integrated community

resources and referral– Integrated population health

education patient portal– Customizable systems– HUB operations advisory– Risk Scoring and stratification– Other proven models on the

same platform

The tools, templates, best practices and processes for Pathways Community HUB certification!

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PREGNANT CLIENT

Leading the Way in Delivering Better Community Health

CCSPathways.com

HealthBridge.care

[email protected] 708-906-3057


Documents

Pathways and the HUB 20180710...3 Pathways Care coordination facilitation tools Patient-centered Identify patient risks Social and traditional health issues identified Actionable &