The Pathways Community Hub Program is a community wide, community based care coordination infrastructure that ensures the highest risk individuals in a community are connected to meaningful health and social services that contribute to positive health outcomes. The Northeast Oregon Network (NEON) serves as the neutral entity that is neither a payer nor a service provider. In the role of the Hub, NEON is dedicated to providing the partner coordination services that help reduce duplication of services, aids in identifying those most at risk, provides training, a community based data system, evaluation of outcomes, and, as the Hub model grows, contracting with payers. Project partners employ the trained community health workers who identify the at risk community members, provide assessment and determine which evidence based pathways to assign. Community Health Workers work with the identified community members to complete the assigned pathways, all with the intent of linking people in need with resources. Once a Pathway is complete, it generates a payment for outcome via a community based data tracking system.

Resources Used

The NEON Pathways Community Hub was planned and designed with resources form the Centers for Disease Control and Prevention through their Small Community Transformation Grant Program, and is being implemented with resources from the Meyer Memorial Trust and the HRSA Office of Rural Health Policy Network Development Grant. NEON staff and partners have worked with the Pathways Hub Model developer, Dr. Sarah Redding, from the Community Health Access Project in Redding, Ohio.

Implementation

Through the efforts of the Small Community Transformation Grant, NEON was able to contract with Dr. Redding for intense project education and design, and had her on site for visits with community partners to help promote the model and generate interest. A Hub leadership team was formed with eight community partners from a three county area, who set to work defining the details of the Hub; which at risk population to focus on, which evidence based pathways to use, and development of the Hub manual that governs all Hub functions and operations. While the Leadership Team worked on defining and agreeing to the significant operational details, NEON staff worked on creating a community based data system to track Hub participant outcomes and provide the invoicing system for this pay for outcome model. NEON staff also worked with all health and social service providers in the area to present contracting options and negotiated rates for the payment for outcome portion of the project. Currently NEON is utilizing resources form the Meyer Memorial Trust and the HRSA Rural Health Network Development Program to provide initial outcome payments, calculate Return on Investment Analyses for specific payers, and negotiate ongoing contract payment rates with public and private payers.

Lessons Learned

NEON is only one of a few sites in the nation utilizing this evidence based practice, which initially developed with an early childhood population, with an adult chronic disease population. One of our lessons learned is that when significantly adapting a model, it is best to utilize a consultant, ideally the model developer, to work side by side to ensure adaptations are in line with fidelity to the model. A second lesson learned is that it will take significant time and effort to meet 1:1 and jointly with project partners in order to gain full support and engagement. NEON held over 450 meetings with 149 partners over an 18 month period in order to gain support for the project. Identifying who those key champion partners will be and working with them as a select group to start is a good way to build momentum.

Results

Work to date on the project has achieved six contracted care coordination agencies, with 20 trained and certified Community Health Workers, seven evidence based pathways chosen, and payment rates and operational agreements negotiated. NEON is still currently in process of working with community members, and hopes to have an initial return on investment analysis by July of 2015. NEON has also successfully completed a robust sustainability plan, with significant input from potential payers as well as engaged partners.

Contact

Lisa Ladendorff
Northeast Oregon Network
Ph: (541) 624-5101
Email