Pathways Community HUB Institute Model: A Regional Approach for Supporting Community Health Worker Interventions

Care management services are commonly used for people with complex care needs. Growing evidence suggests that care management interventions that integrate community health workers (CHW) who share similar health and life experiences with the people they serve can improve health outcomes. However, many community-based organizations (CBOs) that employ CHWs may not have the necessary infrastructure to facilitate contracting with health care entities. Community care hubs can support partnerships between CBOs and health care entities by coordinating administration and infrastructure for a network of CBOs. The Pathways Community HUB Institute (PCHI) Model is an example of a community care hub approach that supports CHWs as critical members of care teams and has demonstrated positive impacts for people with complex health and social needs.

Background

The PCHI Model was started in the 1990s by physicians Mark and Sarah Redding, who sought to develop a care coordination program to address the social needs and health disparities they saw in their patient populations. Initially partnering with CHWs to improve birth outcomes, they experienced the challenge of sustaining and scaling a CHW program through temporary grant funding. Over the following decades, in efforts to develop and sustain the CHW workforce, they refined the model by creating a method that tracked progress toward addressing health and social risk factors, tied payment to outcomes, and built regional networks to support a population health approach. In 2015, the Reddings established the Pathways Community HUB Institute to help scale the model. PCHI provides training and certification to support organizations in implementing Pathways Community HUBs (PCHs) nationwide. Currently, organizations in 43 regions across 18 states are implementing or working toward implementing the Pathways Community HUB Institute Model.

Intervention

The PCHI Model is a regional approach to addressing individuals’ health and social risk factors. The model addresses longstanding challenges with care coordination, including duplication and siloing of care across organizations that can result in ineffective interventions. Additionally, PCHs play a key role in using care coordination data to address systemic barriers and unmet needs through policy, and programmatic changes. Key components of the PCHI Model include:

• Regional networks to support aligned care coordination and interventions across different entities, such as CBOs and health care providers;
• CHWs who work with individuals through home visits to address health and social needs;
• Standardized “Pathways,” or approaches, to addressing health and social needs that guide CHW work and enable outcomes tracking with a standardized data model;
• Outcomes-based payment to fund and incentivize addressing health and social needs; and
• Braided funding to align resources to implement the standardized PCHI Model of community-based care coordination to address risk factors.

 The model is delivered through a network of organizations, including:

• A Pathways Community HUB (PCH) that serves as the central administrator of the model. PCHs are responsible for building relationships and contracting with partner organizations, contracting with payers, managing payment to network partners, managing data, conducting trainings, quality improvement, and overall administration. There is only one PCH per region. A wide variety of nonprofit organization types can serve as PCHs (e.g., health care associations, community action agencies, or community-based foundations) as long as the entity is based in the community it serves, can serve as a neutral, trusted convenor, and has sufficient administrative capacity. Multiple PCHs in a state can work together as statewide networks.
• Individual Care Coordination Agencies (CCAs) that employ CHWs and contract with PCHs. CCAs are trained in the PCHI Model and engage and address the needs of individuals served by the PCH’s network. They collect and send data to the PCH, and are paid by the PCH based on engagement and completed "Pathways" (risks addressed).

Health care providers and systems cannot serve as PCH organizations themselves (since PCHs need to be neutral entities) but are critical partners and can serve many different roles within a PCH network. A key goal of the PCHI Model is to bring different sectors together to meet the full range of patient needs. For many PCH networks, health care provider organizations have played a central role in helping to initially create a PCH, including start-up funding. Once the model is up and running, health care providers and systems are important referral partners (e.g., both in terms of referring patients to PCHs to be connected with CHWs and accepting PCH referrals for patients that need to be connected to medical services). Health care providers can also serve as CCAs that employ CHWs working through the PCH, may serve on community advisory councils overseeing implementation, and can be funders for certain populations served by the PCH.

CHW Role

CHWs are a core component of the PCHI Model, working in the community to identify, engage, and support individuals with complex needs. Specific processes vary by PCH network, but in general, CHWs conduct outreach to individuals referred to them by network partners and may find individuals within the community who may benefit from their support. For example, Toledo/Lucas County CareNet (CareNet), an Ohio-based CCA partnering with the Northwest Ohio Pathways HUB and primarily serving clients who are on Medicaid or uninsured, usually connects to individuals based on referrals from PCH partners such as doctor’s offices. CHWs receive referrals from the PCH’s care coordination system and work to connect with individuals through phone calls and letters explaining what supports their program can offer. CHWs at CareNet also directly engage people who may benefit from their support at community events and gathering places (e.g., libraries, laundromats, and hair salons).

Once a client is engaged, CHWs meet with individuals, usually in their homes, to conduct an in-depth conversational needs assessment and help address identified health and social needs. Depending on patient needs, CHWs may work with individuals for as little as a few months to as long as a few years. CHWs at CareNet, for example, often help individuals connect with health and social services, while also helping them develop the skills to manage their care. For instance, CHWs may help someone find a network provider, schedule an in-network doctor appointment, and ensure they have the confidence to perform the task independently. CHWs will also accompany individuals to appointments (e.g., to doctor appointments, court, social security offices) to provide support and help advocate for their needs.

CHWs approach their work through the PCHI Model’s system of “Pathways”— standard approaches for addressing identified risk factors and gaps in care. The model includes 21 Pathways related to social needs, behavioral health needs, access to care, and pregnancy-specific services, each tied to a measurable outcome. "Pathways" are aimed at defining CHW roles in achieving the outcome and are opened when a need is identified, closed when the defined outcome is reached, and provide a standard way to track progress. For example, one “Pathway” is food security, which is completed when the target outcome of “Household member(s) had access to adequate food for 30 days without CHW assistance” is reached and documented. The standardized "Pathways" approach and social care data model, supported by the PCHI certification process for organizations serving as PCHs, helps ensure the work is impactful and gives government and philanthropic funders and health plan payers confidence in the model's value.

Payment

Philanthropic and government grants initially fund most PCH activities. As PCH networks mature, their work is often sustained by braiding various funding sources, including government or philanthropic grants and contracts with health plans. Many PCHs have found success contracting with Medicaid managed care organizations and some are beginning to pilot contracts with Medicare plans. The ultimate goal is to negotiate payment arrangements where a portion of the payment is tied to outcomes. When care coordination payment is tied to volume of services, as is common, the focus tends to be on completing activities regardless of impact. Tying payment to outcomes better incentivizes data tracking and problem-solving across the network to achieve shared goals. It is helpful to link payments to outcomes to demonstrate the model’s impact on funders, including health plans. As Brad Lucas, MD, Chief Medical Officer at Buckeye Health Plan, described, his plan expanded contracts with PCHI Models when “I was able to scientifically show some improved clinical outcomes and cost savings.”

Jan Ruma, President and CEO of PCHI, explained that the PCHI Model is based on a goal of 50 percent of payment tied to successfully closing “Pathways” by meeting pre-defined target outcomes, with the remaining 50 percent tied to participant engagement, measured by at least one documented home visit per month. This balances developing a trusted relationship with the importance of that relationship, resulting in not only identifying risk factors but also addressing them. It is also important to recognize that the network will not have a 100 percent success rate in completing “Pathways’” goals due to factors outside their control. The uncompleted “Pathways” create the quality improvement agenda for the PCH and the community at large. For the outcomes-based portion of payment, the PCHI assigns “outcomes-based units” to each “Pathway,” recognizing that different “Pathways” require different levels of effort. This outcomes-based unit represents the level of care coordination effort typically required to achieve that “Pathways” target outcome. In negotiating contracts with health plans, PCHs typically negotiate a payment rate for the outcome-based unit, and payment is weighted by how many outcome-based units are assigned to each “Pathway.” For the client engagement portion of payment, PCHs typically negotiate a monthly payment rate when there is at least one documented CHW visit each month.

Impact

The strongest evidence for the PCHI Model is related to supporting maternal and child health. One study evaluating a precursor to the PCHI Model found that the program reduced the risk of low-birth-weight babies among women participating in the program from 2001‒2004. An evaluation of 2017‒2020 data for another PCHI program in Ohio found participation was associated with greater prenatal care utilization.

As PCHI programs expand, they are also beginning to explore the impact on broader populations. A PCH in Ohio has used the model to serve adults with low incomes and at risk of chronic disease. Between 2015‒2017, the program served 651 individuals, and addressed over half of their 3,515 identified risk factors. An evaluation of 2019‒2021 data from a PCH in Washington State found that the program helped adults with Medicaid coverage access primary, specialty, and outpatient mental health care.

As qualitative examples of PCHI program impact, Julie Grasson, Executive Director of CareNet, recalled the experiences of some of her organization’s clients. One woman who was connected to CareNet as part of a pilot with a Medicare plan was experiencing a high number of hospital admissions due to multiple health conditions. Additionally, she was the legal guardian for four great nieces and nephews but faced eviction as more family members lived in her home than were on the lease. The CareNet CHW working through the Northwest Ohio Pathways Community HUB helped connect her to a new cardiologist to better manage her congestive heart failure. The CHW also helped connect her and her family to various social services, such as a new subsidized housing arrangement, food assistance, and a door-to-door support service for people with disabilities. Another individual was habitually calling 911 for non-emergency situations and experiencing frequent hospitalizations. The CHW helped connect her to mental health services, which resulted in the correction of a misdiagnosis of paranoid schizophrenia to early onset Alzheimer’s. After the diagnosis was made, the CHW supported this woman with health education and helped her select a nursing home.

Implementation Lessons

Following are key lessons for implementing the PCHI Model drawn from the experiences of PCHI, Toledo/Lucas County CareNet, and Buckeye Health Plan.

It is important to communicate the full value of the PCHI Model to payers. The PCHI Model’s full value comes from how the model supports community-wide infrastructure and cross-organization collaboration to comprehensively address a wide range of risk factors that impact patient health outcomes. Payers supporting the model get more than just CHW-supported care coordination services. By contracting with a PCH, a payer and their members benefit from the whole network of organizations that PCH supports, which are deeply embedded in the community. As Dr. Lucas from Buckeye Health Plan described the first time he was introduced to the model, “I was a little bit naive, and I thought it was almost duplicating some things that we might be doing. But it was not long after that that I realized that this would help us tune into every community across Ohio and deliver on our commitment to more holistic care beyond traditional care coordination services.”

Collaboration between PCHs and health plans is needed to identify common goals and develop mutually beneficial partnerships. While PCHs and health plans are aligned in their mutual goal of improving health outcomes, factors such as state/federal regulations, competing priorities, and low Medicaid margins mean plans are often limited in how much they can fund social services and supports. Plans may only be willing to support a narrower range of social interventions than CHWs and PCHs seek to provide. Ongoing collaboration is important for identifying common priorities, such as engaging plan members and improving access to care, developing an evidence base for the PCHI Model, and ensuring that implementation meets the needs of all parties.

The PCHI Model is a comprehensive approach for organizing community-based care and successful implementation takes time. The PCHI Model is complex and has many components, but for optimal outcomes, organizations should avoid skipping key steps. The model’s comprehensive approach (e.g., components such as robust CHW training, community-based governance, cross-sector partnerships, data collection, and outcome-based contracting) helps build the model from the community up. Once base components are in place, the whole structure helps make the root causes of poor health outcomes visible and provides a structure for PCHs and their networks to address these issues. Doing just some of the pieces will not have the same impact. Implementers should recognize that systems change and breaking down longstanding organizational silos takes time.

Acknowledgments

Thank you to the following individuals who helped inform this profile:

• Julie Grasson, Executive Director, Toledo/Lucas County CareNet
• Brad Lucas, MD, Chief Medical Officer, Buckeye Health Plan
• Jan Ruma, President and CEO, Pathways Community HUB Institute