WHAT IS THE PATHWAYS COMMUNITY HUB MODEL? 

The Pathways Model is a tool that can, if properly used, shift the focus of the {delete activity-based} health and human service systems {add "from activity-based} to outcomes. Pathways are unique in that the outcomes are tracked at the level of the individual being served.  It is the sum of the individual outcomes that will begin to impact the persistent problem of health disparities. Each step of the Pathway addresses a clearly defined action towards problem resolution. Many steps deal with social and cultural issues, and these steps are just as important as the traditional activities of the health and human service systems. 

Pathways have been developed for many issues, including homelessness, pregnancy, medical home, immunizations, lead exposure, and childhood behavior issues, just to name a few.  One client (or patient) may be assigned to many different Pathways depending on the problems identified.  At first glance, Pathways may resemble clinical guidelines or protocols. They are, however, quite different. In a protocol, accountability is not in a specific sense taken into consideration.  If the patient does not show for follow-up appointments or the medication is not being taken correctly, then the provider is not held accountable as long as he/she followed the protocol. This is not the case in a Pathway. The Pathway is not considered complete until an identified problem is successfully resolved. 

WHAT IS THE PATHWAYS COMMUNITY HUB MODEL (PCHM)? 

The Pathways Community HUB Model (PCHM) is a comprehensive, evidence-based community care coordination system.  The PCHM is used to identify those at greatest risk of poor health outcomes, connect them to evidence-based services, and measure the results. A call for accountability by Tom Scheid, Administrator for the Mansfield Department of Jobs and Family Services inspired the inclusion of pay for performance and the first 7 Pathways were developed.  Then Samuel Starr, who later became the CEO of an international technology firm, {Sterling Enterprises,} strongly suggested definition of meaningful units of work that allow accountability and payment for units of work completed.  A multi-disciplinary team was convened and created the additional Pathways used today. 

WHAT CAN THE PCHM DO FOR YOU? 

The Pathways approach allows communities to build a pay for performance system, and is a platform for health plans, health systems, providers, foundations, and community groups to collaborate {effectively}. Data can be shared across systems to measure and control costs and document risk reduction and health results. National certification is now possible for Pathways Community HUBs to ensure quality and increase access to sustainable funding streams.

WHO SUPPORTED THE DEVELOPMENT OF THE PCHM?

Pathways was developed with support from the U.S. DHHS (HRSA, CMS and AHRQ), the State of Ohio, national and local foundations, including the Kresge Foundation, and has been expanded through recent state legislation, and financial support in numerous states/cities. Research demonstrating improved results and cost efficiency have been published, including by the Maternal and Child Health Journal, Academy Health, and CMS.  The Pathways Community HUB model uses and advances a value-based payment strategy and is the bridge to create mutually beneficial cross-sector partnerships.  

WHAT ARE THE PRIMARY COMPONENTS OF THE PATHWAYS COMMUNITY HUB MODEL?

  • Core Pathways: measurement tools to define the problem to be addressed (health or social issue), the desired measurable outcome, and the key intervention steps to achieve the outcome.

  • Community HUB: a regional point of registry and outcome tracking that networks together health care providers, social service agencies, and health care payers that implement these Pathways.  The {HUB is the}point of contact and the site for bridging Pathways information to the healthcare ecosystem and others.

  • Pathway Payments: payment for care coordination that is based on outcomes instead of activities.

HOW IS QUALITY ASSURED WHEN IMPLEMENTING THE PCHM?

The Rockville Institute operates the Pathways Community HUB Certification Program (PCHCP).  The program promotes accountable care through the certification of organizations that use formal and standardized processes in the delivery of community care coordination services. Fundamental to {an organization's} certification is the use of the Pathways Community HUB Model of care coordination which promotes accountable, quality care to measurably improve outcomes, and links payment to performance. Community HUBs that use standardized Pathways and meet the eligibility requirements are welcome to apply for PCHCP certification.