Pathways Community HUB: A Model for Coordination of Community Health Care

Overview of the Pathways Community HUB Model

The Pathways Community HUB Model is a delivery system for care coordination services provided in a community setting. There is considerable variation in how community care coordination models are defined, and this variation is reflected in how they are characterized and operationalized. Community-based coordination for some programs refers to transition from a medical facility (a hospital) to the community (residence or nursing home). In this case, the community involvement is limited to the patient's home or nursing home. In others, the coordination involves multiple providers and services within larger community settings. ^{1 –3} The Pathways model provides a unique strategy to effectively supplement clinical services with the social services needed to overcome social barriers to health for those most at risk. Currently, silos exist around such agencies because there is very little communication among them and even less coordination. Where it has been implemented, the HUB coordinates agencies and service providers in the community to eliminate the inefficiencies and duplication that exists among them. At the foundation of the model are these primary features: 1) Core Pathways, 2) the HUB itself, and 3) payments linked to outcomes. Pathways are standardized measurement tools used to define and track an issue at the individual level from identification through to a measurable completion point. Pathways focus on both health and social issues that need to be addressed to increase the likelihood of a positive outcome for the individual. Twenty Core Pathways have been developed for many issues, including obtaining health insurance, finding a medical home, pregnancy, developmental screening, and tracking social service referrals for issues such as housing and employment (Redding, unpublished data, 2014). The HUB is a regional point of registry and outcome tracking that networks together community care coordination agencies, providers, and payers. The HUB uses Pathways along with other metrics to monitor progress at the individual, care coordinator, agency, and regional level. Coordinated care Pathways are associated with payment for specific benchmarks along the Pathway – the highest payment is provided for successful outcomes at completion. In this way, Pathways provide the infrastructure to link payment to outcomes, thereby linking payments to performance. ⁴ Developed in 2004, the model was recognized by the Agency for Healthcare Research and Quality Innovations Exchange learning network of some 20 organizations. ⁵ However, a community may encounter many challenges to implementing the model because of the extensive collaboration required to make it work.

Uniqueness of the Model

The Pathways Community HUB model is unique in that the outcomes are tracked at the level of the individual being served. Each step of the Pathway addresses a clearly defined action toward problem resolution. One client (or patient) may be assigned to many different Pathways depending on the problems identified during the initial interview and subsequent home visits. This concept differs from guidelines or protocols also referred to as clinical or critical pathways ^6,7 for which accountability is not deliberately taken into consideration. If the patient does not keep follow-up appointments or the medication isn't being taking correctly, then the provider is not held accountable as long as he/she followed the protocol. In contrast, the Pathway is not considered complete until its identified problems have all been successfully resolved. Conversely, at some definitive point, a Pathway that has not been successfully completed must be closed in a documented fashion. The structure of a Pathway and the meaning of its steps are summarized as:

Coordination by Community HUB Pathways

The HUB model requires extensive change on many levels—contracting, payment methodology, and collaboration. The Pathways Community HUB model not only requires that all care coordination activities in a region be transmitted through a central organization (ie, the HUB), but also that payments are directly aligned with the production of positive outcomes through the Pathways. The model works toward elimination of duplication in care by routing all interventions through the HUB and using Pathways to coordinate the pairing of individuals and agency-based care coordinators. With information stored about the current state of such pairings, the HUB can assure that only one agency and one care coordinator is assigned to an individual in any service category. Besides improving delivery of health care services to the community, the Pathways Community HUB model affords significant benefits to the payers of health services as well. Payers save money because of efficiencies afforded by dealing with only one HUB rather than a multitude of individual agencies. Savings also accrue because of the reduction/elimination of redundant services. Some of the key Healthcare Effectiveness Data and Information Set (HEDIS) measures line up with Pathway completion steps (eg, postpartum appointments, well-child visits, immunization screening). Thus, successful completion of such Pathways implies that health plans get paid for higher HEDIS scores and benefit from better National Committee for Quality Assurance evaluations. Of course, there are costs incurred in establishing and running a HUB that otherwise would not be present. Such costs vary with individual circumstances such as the size of the Community HUB, the number of agencies and care coordinators, and the customization needs of the HUB. Communities that wish to consider establishment of a HUB must undertake to analyze these costs using suitable financial tools and determine whether the return on investment justifies the expenditure.

Fee-for-performance inevitably has consequences in the environment engendered by adoption of the Pathways Community HUB model. The payment-for-outcomes methodology requires community care coordinators to successfully complete Pathways in order to receive payments. Care coordination agencies must adapt to become more focused on client needs (patient-centered) in order to be successful with this model. Although this benefits the community overall, individual agencies may not be able to survive financially if they cannot adapt quickly enough to meet the demands of the new business environment. Therefore, the HUB organizing agency must monitor the situation to assure that the current array of services offered is adequate to serve the community.

Limited Spread Related to Implementation Hurdles

Given its advantages and potential for cost reduction and quality improvement, we turn to the challenges faced in expanding the adoption of the Pathways Community HUB Model. The limited spread of the HUB Model is attributable to its requirement for collaboration at many levels – regionally with the agencies participating in the HUB and at the state level brought about by its requiring payment for outcomes using Pathways. Such collaboration is not easily brought about. To overcome such challenges, communities need technical assistance to implement a Pathways Community HUB. This involves identifying and training collaborative partners and putting the HUB infrastructure in place with its associated technology costs, and contracts that reflect payment for outcomes. The growing need for such assistance is being addressed by the development of a certification process which is discussed in the following section. The Pathways Community HUB Model will not support agencies that choose to work in silos in the community. This creates a novel challenging environment for communities that have been functioning on a purely competitive basis; agencies competing for clients and funding have had little incentive to collaborate with other agencies and programs as the HUB requires. Payers also may be concerned about the cost/benefit ratio as there are more up-front costs to produce future cost savings. Therefore, more research needs to predict how the HUB model will impact current funding streams.

HUB Certification

Standards for certifying Community HUB programs are being developed by a collaborative group that includes the Community Health Access Project (model developers), the Rockville Institute, Communities Joined in Action, and the Georgia Health Policy Institute (Leath et al, unpublished data, 2013). The standards include prerequisites for a community-based organization to become a recognized Pathways Community HUB. The potential HUB must meet standards in the areas of governance and administration, organizational infrastructure, client identification and enrollment, scope of services, and accountability. In addition, standards are specified for the agency that is responsible for HUB operation. Many of these prerequisites and standards explicitly, or implicitly, identify requirements for compliance to standard Pathway specifications, or would be greatly enhanced by having such standards to reference (Leath et al, unpublished data, 2013). For example, the prerequisites for a potential HUB include that its operation be based on the Pathways Community HUB Model, and that it has the ability to track outcomes using standard Pathways and to tie measured outcomes and results to dollars within financial contracts with payers. Scope of service standards include the requirement that the HUB utilize Pathways from the list of 20 Pathways and service codes to be provided. The Care Coordination Agency must have a Quality Improvement Plan and performance measures that are monitored and used to inform quality improvement planning. It must have financial contracts that link payments to accomplishment of Pathways care coordination milestones and a systematic method to track and monitor client services and care coordination service program performance. The agency's data infrastructure is allowed to employ either paper-based manual or automated tracking to report on the number and type of clients in total and per care coordinator,

Future Outlook

In contrast to other community care coordination models, the Pathways model employs community health workers, who are frequently from the communities they serve and are central to recruiting high-risk populations in nontraditional community-based environments. Indeed, targeting patients at highest risk is a major distinguishing feature of the Pathways model and a source of potential savings for other programs. ² Most significantly, the Pathways Community HUB Model is distinguished by its use of Pathway-based tracking and documentation, and the associated outcome-based payment and agency-level coordination. A recent study ⁸ provides a formalization of Pathways that serves as a basis for process improvements in coordination of care involving computerized support for more complete and consistent Pathway reporting, improved client adherence to their recommended activities, and improved coordination among the payers and agencies involved. The analysis also indicated that the HUB process can be improved by streamlining the enrollment process to make it faster and more community-based thus leading to higher retention and more effective intervention.

Were it in more universal use across the country, the HUB model would replace the un-coordinated system we have in place now: untracked and unaccountable outcomes, fee-for-service payment contracts, and coordinated care agency silos leading to inefficient, ineffective, and costly health care delivery.