Omaha to Deploy Pathways Community Hub Model to Address Disparities

May 23, 2022
Community health workers will connect community members with resources to improve modifiable risk factors related to poor birth outcomes

Stakeholders in Omaha, Nebraska, are joining the Pathways Community Hub initiative to addressing health disparities among low-income pregnant/postpartum people. A community-based organization will be chosen to serve as the Pathways Community Hub Entity and receive $1 million for the first two years of infrastructure development and operations.

The Ohio-based Pathways Community Hub Institute (PCHI) has developed a model of evidence-based, community-driven care coordination designed to address health disparities. Community health workers connect community members with resources to improve modifiable risk factors that predicate a variety of poor health outcomes.

The PCHI Model is described as leveraging a standard risk assessment and care coordination protocol, social care data system, and 21 standard pathways to measure outcomes, such as stable housing, the establishment of a medical home, completion of prenatal care, and a healthy weight newborn. Certified Hubs exist in 17 communities and are being implemented in many more locations nationwide, according to PCHI.

The organization said that the Northwest Ohio Pathways Community Hub (Centene Ohio Plan) demonstrated that high-risk mothers without Pathways Community Hub (PCH) intervention were 1.6 times more likely to deliver a baby needing special care. For every dollar spent on PCH for Centene members, there was a savings of $2.36.

Newborns born to mothers at high risk enrolled in the Hub have a per member/per month cost savings of $379 during the first year of life compared to those born to mothers not enrolled in the Hub at delivery.

Speaking during a recent webinar for potential Hub organizations in Omaha, Jan Ruma, president and CEO of the PCHI, said Omaha is far from alone in experiencing disparities in birth outcomes, especially among African-American and Hispanic populations.

“This model has been proven to help close that gap,” Ruma said. “Once the core team has identified an organization to implement the Pathways Community Hub model, you will have a community-based care coordination network that will focus on value-based, outcome-oriented care coordination that will result in a quality improvement framework that will address both health and social needs, and then work to close those gaps.”

Ruma noted that Omaha will be leveraging the skills of community health workers to find and engage residents who are under-resourced and at the greatest risk of poor health outcomes. “You'll be attracting payers that don't normally invest in the social care space,” she added. “We have seen Medicaid managed care plans really rally around the model as a way to help their members improve their health. Also, it helps them to reduce costs because people get connected to preventive care and are able to prevent poor and expensive birth outcomes and other health outcomes. At the end of the day, through really rigorous implementation of this model, you'll be able to improve health, reduce costs, and promote health equity.”

She said the approach is about bringing a whole community together to address a huge issue as opposed to one organization trying to solve it alone. Some of the key components that makes the model unique from other service delivery programs is that it is a standardized approach requiring national certification to implement the model with fidelity using a standard social care data model. “Whether you're a hub in Omaha, or a hub in Wisconsin, you're collecting the same kind of data, yet you're able to customize the intervention to some degree based on your existing resources,” she said.

There are 21 standard pathways in the model that help community health workers to identify and track risk factors, and work to eliminate those risk factors one by one, in partnership with the residents that they're working with. “Payment is directly linked to risk reduction defined by the pathways,” Ruma said. “Everything you're doing is focused on quality improvement and meeting the needs of residents.”

The Omaha Hub will start by focusing on pregnant women east of 72nd Street, where there's the biggest burden of disparity. They will be looking for organizations and healthcare providers to refer pregnant women who could benefit from this intervention.

It is a two-year grant period for implementations with plans to start Aug. 1 of this year, with completion at July 31, 2024.

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