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Connecting those at risk to care: the quick start guide to developing community care coordination pathways

Pathways Community HUB Institute, Community Care Coordination Learning Network
Agency for Healthcare Research and Quality (AHRQ)

This Quick Start guide complements Pathways Community HUB Manual: A Guide To Identify and Address Risk Factors, Reduce Costs, and Improve Outcomes, initially published in 2010 by the Agency for Healthcare Research and Quality (AHRQ). The publication provides a detailed overview of the Pathways Community HUB (HUB) Model. The HUB is a community care coordination approach focused on reducing modifiable risk factors for high-risk individuals and populations.

The HUB relies on community care coordinators (CCCs)—community health workers, nurses, social workers, and others—who reach out to at-risk individuals through home visits and community-based work. Once an at-risk individual is engaged, the CCC completes a comprehensive assessment of health, social, behavioral health, economic, and other issues that place the individual at increased risk. Each identified risk factor is tracked as a standardized Pathway that confirms the risk is addressed through connection to evidence-based and best practice interventions.

The Pathway is a tool for confirming that the intervention has been received and that the risk factor has been successfully addressed. The Pathway also serves as the quality assurance and payment tool, and it is used by the CCC to ensure that each risk factor is addressed and that outcomes have improved.

When this model is deployed across multiple agencies within a community, the centralized HUB helps agencies and CCCs avoid duplication of effort. The HUB serves as a communitywide networking strategy that helps isolated (“siloed”) programs become a quality-focused team to identify those at risk and connect them to care.

The HUB model was first developed by the Community Health Access Project (CHAP) in Mansfield, Ohio, with leadership from Drs. Sarah and Mark Redding. The model involves working across organizational silos within a community (CHAP worked with multiple stakeholders in three counties) to reach at-risk individuals and connect them to health and social services that yield positive health outcomes. The model is now part of a national network of community-based initiatives (Appendix A) working under a common set of national standards and certification developed by the Pathways Community HUB Institute.

This quick start guide is a reference and resource for public and private stakeholders engaged in improving the community care coordination system for identifying high-risk individuals; documenting their specific health, social, and behavioral health risk factors; and addressing those risks in a pay-for-performance approach. The HUB focuses on individuals and populations, and it provides coordination, measurement, and impact data that can help guide local and regional policies and reimbursement strategies. The target audience includes all those involved in the design, implementation, and financing of care coordination services, especially within the community setting.

This guide includes an overview of the process, as well as tools and resources needed to develop a HUB. Additional information on the HUB model and Pathways is available in the full manual.

Pathways Community HUB Institute, Community Care Coordination Learning Network. Connecting those at risk to care: the quick start guide to developing community care coordination pathways. A companion to the Pathways Community Hub Manual. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); January 2016. AHRQ Publication No. 15(16)-0070-1-EF. Available online.
 

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