2. “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 ?
3. Current Community Care Coordination
HHS MEDICAID
MANAGED
CARE
EARLY
CHILDHOOD
CHILD
PROTECTIVE
SERVICES
HEALTH
PLAN
Marisol Angelina Mrs. Garcia
Multiple care coordinators involved –
limited communication
5. Social Determinants of Health
Poor Infant Mortality Rate
Social
Determinants
of
Health
Occupation
Education
Culture
Socioeconomic
Status/Income
Neighborhood Race/Ethnicity
7. 7
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
8. 8
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
10. Measure
10
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 Medical
Home
Pregnancy Social
Service
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…
12. 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
13. LBW in Richland County
13
7
7.5
8
8.5
9
9.5
10
2005 2006 2007 2008
PercentofLBWBirths
Low Birth Weight Rates in Ohio and
Richland County: 2005-2008
Richland
Ohio
14. 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
15. 13.4 13.2
9.5 9.5
0
2
4
6
8
10
12
14
16
Ohio 2013 Lucas
County
2013
Pathways
2013
Pathways
2014
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-partum
appointment within 90 days
16. 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: Multiple
chronic
disease
17. Distinctions between Pathways & HUB
17
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
18. One Care Coordinator for the Entire Family
Marisol
Angelina
Mrs. Garcia
18
• 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
25. 25
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
26. 26
Standard Billing Codes
Normal
Risk
High
Risk
Modifier
Checklists
Initial Pregnancy
Checklist
Completed one time at Member enrollment, 1st
trimester engagement
G9001 G9003 R1
Completed one time at Member enrollment, 2nd
trimester engagement
G9001 G9003 R2
Completed one time at Member enrollment, 3rd
trimester engagement
G9001 G9003 R3
Pregnancy
Checklist
Completed at each face-to-face encounter with
Member
G9005 G9010 R
Pathways
Behavioral Health Kept three scheduled behavioral health appointments G9002 G9009 RB
Education Educational module delivered. G9002 G9009 RE
Family Planning LARC (long-acting, reversible) or permanent method G9002 G9009 G1
Family Planning All other family planning methods G9002 G9009 G2
Housing Residing in affordable & suitable housing for 2
months.
G9002 G9009 RI
27. 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
27
28. Endorsers of the Pathways Community
HUB Model
The CMS Innovation Center
29. 29
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.
30. 30
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
