Charting A Pathway To Better Health
2018; Project HOPE; Volume: 37; Issue: 12 Linguagem: Inglês
10.1377/hlthaff.2018.05166
ISSN2694-233X
Autores Tópico(s)Health disparities and outcomes
ResumoLeading To HealthDeterminants Of Health Health AffairsVol. 37, No. 12: Telehealth LEADING TO HEALTHCharting A Pathway To Better HealthT. R. Goldman AffiliationsThis article is part of a series on transforming health systems published with support from The Robert Wood Johnson Foundation. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/licenses/by/4.0/. T. R. Goldman ([email protected]) is a Washington, D.C.–based freelance journalist.PUBLISHED:December 2018Open Accesshttps://doi.org/10.1377/hlthaff.2018.05166AboutSectionsView articleSupplemental MaterialView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits View articleAbstractIn Toledo and other communities nationwide, a new approach to care coordination is reaching patients where they live.TOPICSCare coordinationCommunity health workersCost consequence analysisQuality of careMedicaidMaternal healthChildren’s healthAccess to careClinical careOn a bright Ohio morning a full month before Halloween, the orange holiday regalia was already out in force at the upscale open-air shopping mall in Perrysburg, ten miles south of Toledo. And in a booth at the local Bob Evans, Mark Redding was sketching a female stick figure to explain the social determinants of health.It’s an intuitive and appealing concept—that such basic, nonmedical factors as employment, education, housing quality, and access to transportation, to name just a few, play a far greater role in health outcomes than direct medical care—and it is now widely viewed as self-evident.Far from obvious, however, is how to resolve, much less mitigate, the deleterious impacts of these often debilitating social determinants of health.Redding, fifty-eight, has long, fine-grained fingers and the benign mien of a veteran pediatrician, and when he doesn’t agree with you, he might push back by saying: “I would nudge you on that.” But on the subject of the Pathways Community HUB, the care coordination model he developed with his wife, Sarah Redding, a fifty-seven-year-old physician who specializes in preventive medicine, his tone is messianic. It is, he says, “absolutely potentially transformative.”The Reddings’ model is rooted in the belief that a meticulous and coordinated attack on an individual’s social determinants of health led by a trained, local community health worker can mitigate many negative social determinants and produce better health outcomes for people at high risk. In some cases, says Mark Redding, such an approach can help families break out of the multigenerational cycle of poverty in which they live.It’s not that “care coordination” is a novel concept. Indeed, along with “social determinants,” it is one of the buzziest phrases in health care today. However, the Pathways HUB model differs from other social determinants models on at least two important counts: First, it manages its clients with community health workers who come from the same neighborhoods as the people they serve. And second, the model’s financial framework is premised on a monetary incentive that is realized by care coordination agencies—that is, the community health workers’ employers—when HUB clients achieve measurable, positive outcomes in a host of factors, both large and small.Central to the Reddings’ model is the targeting of “individual modifiable factors of risk,” with risk being defined as a lack of something—be it housing, a medical home, food, employment, or training in parenting skills or nutrition. In other words, risk is any social determinant that leads to an unwanted medical or socioeconomic outcome.Just as important, however, is the notion that these risk factors are linked. An expectant teenage mother at risk for a low-birthweight, preterm delivery who is simultaneously homeless, depressed, and without access to medical care must have all three factors addressed, since fixing one by itself is unlikely to make much difference in the outcome, says Mark Redding. “You can’t break people apart and treat their parts.”Step By StepThe technical tool used to track the individual modifiable risk factors of each client is known as a Pathway, an ordered checklist, of what needs to happen, step by step, to resolve a particular issue. “It simplifies a complex situation into a manageable unit and gives you something you can wrap your arms around,” says Jan Ruma, who has run the Northwest Ohio Pathways HUB in Toledo since its inception in 2007.1 “Let’s take this one by one: ‘What is your biggest need, and let’s work on that Pathway first.’”There are twenty Pathways in the HUB model, ranging from housing to postpartum services and a behavioral health referral. There are broad Pathways such as social services, which includes twenty-five subcategories or tools such as a telephone, food stability, or a plan to start tackling medical debt. (See the online appendix exhibit for a description of the twenty primary Pathways used by any certified Pathways HUB.)2Each Pathway has an outcome, a specific metric that must be completed before the community health worker’s employer is paid—typically by the patient’s managed care plan or a government entity such as a local department of health.Under the model, at least half of all payouts must be tied to a confirmed risk mitigation—for example, a previously unemployed client has been hired and is still working thirty days later, a former smoker has gone one month without a cigarette, or a child with no medical home has been to see his new doctor and completed his enrollment. Other, generally smaller payouts go for non-outcome-based processes such as receiving screenings from or having an initial visit with a health care provider, or connecting to a community resource such as a food bank.Normally, under other care coordination models, says Sarah Redding, community health workers “are paid to do home visits or fill out forms. We don’t pay them to resolve the issue.” The HUB requires a new mind-set from community health workers and their employees, she says, and “it’s hard to get them to switch over. ‘I have to make something happen to get payment?’” It even took time to convince funders that they, too, could demand outcome measurements in exchange for their money, she adds.“Part of the beauty of the model is that they hold their people accountable for identifying and lowering risk at a higher level than anyone else in health care—more than providers and more than payers,” says Brad Lucas, senior medical director at Buckeye Health Plan—a subsidiary of Centene Corporation, which is one of the five managed care plans available to Ohio Medicaid patients. “In a sense, it’s low tech and it’s cutting edge.”Often Pathways are not completed, and there is no payment. “If we have a low-birthweight baby, no matter how much work they’ve done, we cannot charge anyone,” notes Barbara Gunning, the performance manager for the Northwest Ohio HUB. “We had one baby off by just a few grams,” she says, referring to the low-birthweight definition of less than 2,500 grams.Yet the collected information on unfinished Pathways can yield valuable data. If behavioral health services are rarely completed, for example, that could demonstrate a need for a larger mental health care infrastructure in the community.Building ConnectionsThe Reddings developed their model about twenty years ago, although its genesis goes back to the late 1980s. That was when, as freshly minted MDs, they moved to the Inuit village of Kotzebue, Alaska, thirty-three miles north of the Arctic Circle, where they spent three years as staff physicians in the only hospital in an area the size of Ohio. There, they were introduced to the practical impacts of community health workers, of having an “embedded, culturally connected individual as a liaison to the medical system who, through his or her relationships with clients, could leverage behavioral change,” Mark Redding explains.A decade later, at their clinic in Mansfield, Ohio, the reality of social determinants was driven home when a client repeatedly failed to make her prenatal visit—until her community health worker found the family a place to live. Mark Redding says the realization that “housing was bolted onto whether she was going to her prenatal visit” was a turning point in his understanding of dealing with high-risk patients.Yet including social determinants in an overall health care program was only one part of the equation. The problem was that even when social determinants were part of a care coordination model, the process typically functioned within Balkanized silos, with the various social service agencies rarely talking together, much less working in tandem on behalf of one client. Care coordination was, and still is, says Mark Redding, “the least evidence based, most disorganized, and sloppiest part of our health care system. It is the low-hanging fruit.”There are now some thirty communities in several states that use Pathways HUBs. The largest and one of the oldest HUBs is in Toledo, with a little more than 2,000 clients expected to be served in 2018—an increase from just over 1,400 clients in 2017. There are three HUBs in Michigan, and HUBs are set to begin operation or are already up and running in six of the nine Accountable Communities of Health that Washington State has been divided into under its Medicaid Transformation Project. There are also pilots in Oregon, Texas, and Wisconsin. And other localities, including Brooklyn, New York; Indianapolis, Indiana; and North Carolina, are considering implementation.There is a formal certification program,3 and two Agency for Healthcare Research and Quality publications on the web provide a step-by-step guide for setting up a HUB.4,5“When we started this, there were no ‘social determinants’ in the big-picture national conversation,” says Ruma of the Northwest Ohio HUB, in Toledo. “Now it’s the sexy thing to say, but this isn’t brain surgery. If you need a house and you don’t have a house, nothing else really matters. You can have the best insulin care, but nowhere to put the insulin.”The Northwest Ohio HUB operates from the headquarters of the Hospital Council of Northwest Ohio, where Ruma is vice president, in a brick office building about ten miles west of downtown Toledo. The HUB is the model’s focal point—the Reddings use the image of an air traffic control tower—a neutral administrative body, unaffiliated with any provider; a sort of coordinator of the care coordinators that trains the community health workers as well. “Our community health workers are nondenominational,” says Ruma. “They can have five clients, each on a different Medicaid plan.” (Almost all of Ohio’s three million Medicaid patients are served by one of the five managed care plans.)The HUB takes referrals for potential clients from a health care provider or community health worker and checks to make sure that the referral is not already in the system and the person is not being seen by another worker. It then sends the referral on to a care coordination agency—a health care system, family center, or even a county department of health. The agency assigns one of its community health workers to visit the potential client at their home and begin the Pathways process.Complex ImplementationHUBs begin life using a classic “braided funding” model, with money coming from any number of sources, ranging from community foundations to governmental agencies. “We’ll take little bitty grants to great big projects,” says Gunning, the Northwest Ohio HUB performance manager. Ideally, as the HUB matures, it will be able to negotiate a fee schedule with philanthropic funders, health departments, and managed care plans, which stand to benefit from the model’s emphasis on correcting the sort of health issues that cost exponentially more than preventive measures do.6The funders determine a particular HUB’s emphasis, ranging from pregnant women to adults with chronic disease. But the key to a HUB’s viability, says Ruma, is growth: “To make this sustainable, you have to be covering a lot of lives.”Once a Pathway is completed, the HUB bills the managed care plan at a contracted rate, keeps a percentage (which could go as high as 30 percent) for its own expenses, and passes the rest on to the care coordination agency that employs the particular community health worker. “We’ll bill anywhere from $30 to $300 for a confirmed social services connection, and this is not just for a telephone number for a crib,” says Ruma. “They actually got a crib.”For a healthy-birthweight baby, for example—an outcome that’s also a quality measure for the managed care plans that is monitored by Ohio Medicaid—a care coordination agency might get paid anywhere from $300 to $700. Still, the actual amount charged “is a lot more art than science,” says Ruma. “How do you figure out the value of finding someone a house? Value is in the eye of the payer.”There’s even the possibility of a bonus for the community health worker when certain specific goals are met. In Toledo, for example, where the local housing authority provided the HUB with twenty-five housing vouchers, there was a deadline to apply for an apartment. So Ruma is giving each community health worker who places someone in a new home a $100 grocery store gift card.“It’s a very difficult story, because it is such an unusual model and starts from a different place,” says Linda Post, chief medical officer for the UnitedHealthcare Community Plan of Ohio, one of the managed care plans in Ohio Medicaid. “It’s a model that starts from the assumption of the person and where the person lives rather than starting from the assumption that ‘Well, medical care itself will make the difference.’ It’s a recognition that it’s not all about medical care.”And it can be a complicated model to implement. “One of the biggest obstacles is the several moving pieces of the model,” says Kimberly Latham, the project manager for Washington State’s HUB implementation.7 “There’s the financing side, the outcome-based payment, developing the HUB, recruiting the HUB network, hiring the community health workers—and you’re concurrently developing the technology side as well and adding your own local matrix,” she says, referring to the information technology platform used by the community health workers to track their clients’ progress.Mary Applegate, medical director of Ohio’s Department of Medicaid, calls the Pathways HUBs “a start, and a step in the right direction,” but she cautions that they are only a “piece of the implementation of a population health plan, not the engine.” At some point, she says, “within Medicaid, we will have to go beyond the remediation of individual risk factors and start to build healthy communities”—a challenge that is “not just the responsibility of the managed care plans” but also of the community and business organizations.For now, she says the HUB program could do a better job of identifying the highest-risk people. “From their perspective,” she says, “anyone in Medicaid is a high risk.”Sarah Redding disagrees. Under the HUB model, “if you sign up people with no issues, you’re just paid for doing a visit, not for an outcome,” she notes. “And if there are no Pathways to resolve, you shouldn’t be in the HUB in the first place.”Face To FacePoverty is an alternative reality, an experiential truth with a corrosive stress whose pervasiveness is difficult to grasp unless one has lived it. Pathways HUB community health workers are able to bridge the gap between the chronically poor and the rest of society because to one degree or another, they have stood in their clients’ shoes.“I was in their situation for many years, with a daughter who had a kid at seventeen,” says Toni Sheets, a community health worker at the East Toledo Family Center, just across the Maumee River from downtown.8 “My daughter’s twenty-one now and owns her own house. But she had her own support system. A lot of times, all these girls need is support.”In a large room at the East Toledo center, Alena Taylor, a Pathways lead coordinator, sits at a right angle from her client, thirty-seven-year-old Marsha Shultz. Taylor, her Pathways tablet in hand, is running through the checklist she uses for her monthly visits with clients and commiserating with Shultz about how hard it can be after giving birth to move from your OB/GYN back to a primary care doctor. Shultz had her eleventh child in June.“She’s the best, she’s delivered my last three kids,” says Shultz, who entered the HUB after being referred from a local pregnancy clinic.“You need to refocus on your family doctor,” Taylor says firmly, looking Shultz directly in the eye. Shultz has had problems getting to the doctor. Her boyfriend had fixed the starter in her car, but then the car started overheating.“Are you stressed?” Taylor asked.“Kind of—there’s a lot going on. I can’t say I’m not stressed,” Shultz answers.“People get stressed,” Taylor responds.“Are you smoking?” she continues, as she moves down the monthly checklist.“I know,” Shultz answers quickly, adding, “I don’t smoke in the house, too many kids.”“Dad doesn’t smoke in the house?” Taylor wonders.“As long as the baby’s not there,” Shultz says.“How many times does anyone read to your child?” Taylor asks.“I sing to him,” Shultz explains, referring to her three-month-old. “He’s a crybaby now. He cries unless you sing to him or hold him.”Taylor is working on finding Shultz a new place to live because her apartment is far too small; her building has bedbugs, which is why Taylor had not visited Shultz at home; and three sex offenders live on the property. “So I’m like, my kids don’t play outside very often,” Shultz explains.“I’d love to be able to meet up with you in the next two weeks,” Taylor says. “We’re tackling the stuff which is the most important.”“I’m determined on this housing,” says Shultz, as she fills out the seven separate birth certificate request forms for the children who will live with her that she needs for the housing application. The cost of the forms ($25 each) will be covered by the Toledo Lucas County Homelessness Board.If Shultz, with Taylor’s assistance, is able to move into safe and stable housing and remain there for at least three months, the East Toledo Family Center will get paid roughly $200 from the HUB. If she stops smoking, the HUB will pay the center about $100.“The hardest thing about this job,” Taylor explains after Shultz has left, “is that you are coming across families in such need, it’s hard to walk out of the house.” Her job, she says, is to “direct” her clients so that “they come up with the answers and find their own way to advocate for themselves. If you do it for them,” she explains, nothing changes, and “it’s a horrible cycle.”Signs Of ProgressToledo, Ohio’s perennial fourth city behind the three Cs (Columbus, Cleveland, and Cincinnati) sits at the mouth of the Maumee River just before it flows into Lake Erie. It’s a rust-belt town built on cheap labor and cheap water. Gloria Steinem was born here, as was jazz pianist Art Tatum, but people tend instead to mention actor Jamie Farr, who played Klinger on M*A*S*H. Once the center of the country’s glass industry, with a sizable refinery business as well, Toledo is picking itself up after the devastating oil crisis of the 1970s and the Great Recession of 2008.Two of the country’s top-twenty health systems by revenue, Bon Secours Mercy Health and ProMedica (which moved its headquarters to downtown Toledo in 2017, complete with a fifty-foot-long outdoor television screen), compete fiercely for business. The low-birthweight rate among blacks in Lucas County, where Toledo is located, is more than 50 percent higher than the rate among whites, according to preliminary 2017 figures from the Toledo–Lucas County Department of Health. The disparity in prematurity is nearly as bad, according to Ruma, who provided the grim statistics.Making a dent in those rates was the principal reason, Ruma says, that the Toledo Community Foundation (the city’s major philanthropy) and the Stranahan Foundation (started by the founders of the Champion Spark Plug Company) each provided a grant of $270,000 in 2006 to get the Northwest Ohio HUB off the ground.Ruma says that only 8.8 percent of the 240 black singleton births in the Pathways HUB in 2017 were low birthweight, while preliminary 2017 data from the Toledo–Lucas County Department of Health put the countywide low-birthweight figure among black mothers at 14 percent. While the HUB sample is far smaller, it is not risk-adjusted, and Ruma points out that each HUB mother had an average of six to seven risk factors as well.“Buckeye Health Plan conducted a retrospective cohort study of each of the plan’s 3,702 deliveries in Lucas County between early 2013 and early 2017,” says Buckeye senior medical director Lucas. It concluded that high-risk mothers with no exposure to the Northwest Ohio HUB were 1.55 times more likely to deliver a baby needing a special care nursery or care in a neonatal intensive care unit, compared to high-risk members who received services from the HUB.“That is statistically significant—a pretty dramatic number,” Lucas notes. He says that the numbers worked out to $2.36 saved for every additional dollar spent during the baby’s first year, including inpatient, outpatient, and pharmacy costs. “And there are, of course, savings down the road that we did not even include,” he adds.In 2015 Sarah Redding and five coauthors published an article in the Maternal and Child Health Journal that compared 115 control births with 115 births in the Reddings’ HUB in Mansfield during 2001–04.9 Fifteen (13 percent) low-birthweight babies were born in the control group, while only seven (6.1 percent) were born in the HUB intervention group, a reduction of more than 50 percent. For pregnant women, a key part of a successful delivery is the simple fact of making and keeping prenatal OB/GYN appointments—finding a medical home and getting there is one of the HUB’s twenty Pathways—which in turn allows the doctor to address incipient medical issues that could otherwise lead to preterm delivery and low birthweight.Hard Work AheadMark Redding still does “runny noses two days a week” at his pediatric practice in Mansfield, Ohio, but since 2016 he has been head of community care coordination and risk reduction at the Rebecca D. Considine Research Institute at Akron Children’s Hospital. He readily acknowledges that “we don’t have a bandwidth of strong publications” that prove the efficacy of the Pathways HUB model, although he says there are currently “eight or nine publications in the works” that focus on nonmedical risk factors, their mitigation, and the potential to improve outcomes and cut costs.If the Reddings want the HUB model to thrive, they will have to convince more health care payers and providers that social determinants are worth tackling.That matters, because if the Reddings want the HUB model to thrive, they will have to convince more health care payers and providers that social determinants are worth tackling—a challenge that many medical professionals still view as outside their purview, akin to asking them to raise the living standards of their poorest patients by a socioeconomic notch. “You can get in a room and start talking about this stuff to senior executives,” explains a medical director at a large health insurer, “and they look at you like a deer in the headlights. ‘What are we supposed to do, build houses?’”Part of the move toward greater acceptability lies in the creation in 2018 of the Risk Reduction Research Network, a consortium led by the Georgia Health Policy Center that also includes Akron Children’s Hospital, Kent State University, and the Pathways Community HUB Institute. The network’s aim is to develop an open-source reference of “weight of impact estimates [for] both singular risks and the combined effects of multiple risks factors…on health and socioeconomic outcomes” so that payments can be directed at factors “most likely to improve outcomes and value.”10Sometimes these factors are not as obvious as they might appear. “Transportation seemed like it made sense,” says Post, of the UnitedHealthcare Community Plan of Ohio. “But on-demand transportation didn’t change any results because we found it’s not really about transportation.” Instead, she said, it’s about a lack of even more important priorities, such as food and housing, that crowd everything else out and make it difficult to plan a trip to the doctor—even when getting there is not the issue.“If we can look across large databases and show there’s value, and state what that value is, that’s a very compelling argument,” says Michael Kelly, Akron Children’s Hospital’s chief research officer. The Pathways model, he says, “needs a stronger foundation of evidence to be more fully marketable to the states and to CMS,” he adds, referring to the Centers for Medicare and Medicaid Services.Ultimately, to fully incorporate the idea of social determinants into modern medicine will require more than simply producing “weight of impact” statistics culled from hospital electronic health records and HUB data nationwide. Providers and the health care system in general must begin an attitudinal shift that focuses more broadly on nonmedical factors and begin to invest in programs that take a holistic view of health.“So instead of the doctor who says: ‘That’s a pain in my rear—one more person in my ER [emergency room],’ the question is, ‘Can you meet them at their most vulnerable?’” says Kent Bishop, who became ProMedica’s chief experience officer in 2017. “And that’s what the HUB does better than anyone.”NOTES1 Hospital Council of Northwest Ohio. Northwest Ohio Pathways HUB 2017 annual report [Internet]. Toledo (OH): Northwest Ohio Pathways HUB; [cited 2018 Nov 5]. Available from: http://www.hcno.org/wp-content/uploads/2018/05/Northwest-Ohio-Pathways-HUB-2017-Annual-Report.pdf Google Scholar 2 To access the appendix, click on the Details tab of the article online. 3 Pathways Community HUB Institute. Pathways Community HUB Certification [Internet]. Mansfield (OH): PCHI; [cited 2018 Nov 6]. Available from: https://pchi-hub.com/what-is-a-certified-hub/ Google Scholar 4 Applegate M, Brennan L, Kuenkele V, Redding S, Redding M. Pathways Community HUB manual: a guide to identify and address risk factors, reduce costs, and improve outcomes [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; 2016 Jan [cited 2018 Nov 5]. (AHRQ Publication No. 15(16)-0070-EF). Available from: https://innovations.ahrq.gov/sites/default/files/Guides/CommunityHubManual.pdf Google Scholar 5 Community Care Coordination Learning Network—The Pathways Community HUB Institute. Connecting those at risk to care: the quick start guide to developing community care coordination pathways [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; 2016 Jan [cited 2018 Nov 5]. (AHRQ Publication No. 15(16)-0070-1-EF). Available from: https://innovations.ahrq.gov/sites/default/files/guides/CommHub_QuickStart.pdf Google Scholar 6 Johnson TJ, Patel AL, Jegier BJ, Engstrom JL, Meier PP. Cost of morbidities in very low birth weight infants. J Pediatr. 2013;162(2):243–49.e1. Crossref, Medline, Google Scholar 7 Better Health Together. Regional health improvement project [Internet]. Spokane (WA): Accountable Community of Health; 2018 Feb 1 [cited 2018 Nov 5]. Available from: http://www.betterhealthtogether.org/bold-solutions-content/pathfinder-community-hub-videos Google Scholar 8 East Toledo Family Center [home page on the Internet]. Toledo (OH): The Center; [cited 2018 Nov 5]. Available from: http://www.etfc.org/Default.aspx Google Scholar 9 Redding S, Conrey E, Porter K, Paulson J, Hughes K, Redding M. Pathways community care coordination in low birth weight prevention. Matern Child Health J. 2015;19(3):643–50. Crossref, Medline, Google Scholar 10 Redding M, Hoornbeek J, Zeigler BP, Kelly M, Redding S, Falletta Let al. Risk Reduction Research Initiative: a national community-academic framework to improve health and social outcomes. Popul Health Manag. 2018 Aug 13. [Epub ahead of print]. Crossref, Medline, Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. 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