PATHWAYS Program

• James – recently Comprehensive staff have had a bunch of pregnant clients connected with CLR – looking for resources we stumbled into ACH Pathways Program, so I invited them to come here and talk about it.
• Liszet Chavez-Avila, Accountable Communities of Health - http://www.piercecountyach.org/ -  Community Engagement Coordinator -  Liszet@piercecountyach.org - 302.5508
• From Arizona – moved here in 2013 – for school and to see rivers with water and hills with trees (flying in to Phoenix and seeing a brown landscape as far as the eye can see –it always makes me think that people shouldn’t be living there.  I love the desert, It’s a nice place to visit, but… –ed).
• What are Accountable Communities of Health (ACH) (question for the audience. –ed.)?
  • Answer - decreasing 911 calls? Liszet - yes, that is one of the goals (person answering got a mystery prize from a bag.  I was envious. –ed).
  • Answer - Started from the Waiver to transform Medicaid? Liszet - yes, this all started from the Medicaid Waiver.  The waiver allows us to use Medicaid funds to do more innovative project and to work with all populations. (another mystery prize – what are they getting??? –ed.)
• The ACH works to connect everyone working with patients together so we can serve our Medicaid population best.  Just because a client have access to healthcare doesn’t mean you will be healthy.  There are other barriers to health (like whipping cream tasting so good? –ed).  It can be housing or transportation or childcare. (well, yeah, stuff like that too, I suppose. –ed.)
• Pierce County is 1 of 9 ACHs in Washington State.  Pierce County has 220,000 Medicaid clients.
• ACH works to connect folks so all providers can all be on the same page in caring for folks.  Each type of provider has a different perspective, and we are working to bring all those approaches together for a patient health outcomes. 
• 4 Main Projects:
  • Bi-direction integration of Care – primary care and mental health together
  • Community care coordination
  • Opioid crisis response
  • Chronic disease prevention and control
• The State Health care authority proposed other programs, but the Pierce County board will be intertwining those programs into the 4 main project.
• Pathways – what is it?
  • Resource for pregnant women?  Yes
  • Treatment? – no
  • It is care coordination – done with community health workers .  They are people who don’t do clinical work or treatment- they help clients know what resources they need, connect them to resources, even help them find resource.  They are not connected necessarily to a specific agency.  They work like a friend or a personal assistant to help clients organize – a bit like a navigator.
  • Started in Ohio 2001  – some providers saw patients were getting care – prescriptions for meds and such – but the clients were not following-up or seeing improvements in health.  Pathways model was created to fix this problem.
  • PATHWAYS HUB began in Ohio – now in Wisconsin, Michigan, New Mexico, (I put that last comma in but didn’t put in another location, so maybe it is in one or two other places with Pathways…-ed)
  • A “Hub” is a place people come to share information.
  • In Washington State – Pierce County is one of first counties to establish a HUB – it is exciting to be one of the first ones (like Beryl Markham – among other things, the first woman to fly solo across the Atlantic East to West.  If you’re looking for a good read, her memoir West with the Night is “a bloody wonderful book”, as Ernest Hemmingway put it.  If you can shake the cloud that hangs over Europe’s colonial past in Kenya, it is a superb story of adventure, a woman busting the social norms of the 20’s, and a zest for life.  She’s a truly gifted author, too.  If you liked Isak Dinesen’s Out of Africa, you’ll love this. Don’t bother with an audio book or kindle – this memoir was meant to be paper in your hand - https://www.amazon.com/West-Night-Memoir-Beryl-Markham/dp/0865477639/ -ed.).
• Al – what is the difference between community healthcare worker, a navigator, and a case manager?  Liszet – interesting question – there is some discussion about what a community health care worker is.  A Community Health Care worker will help connect them to other resources usually outside of their own agency. 
• Video (https://www.youtube.com/watch?v=4-JE0xvTGvM ) – What is pathways community based care coordination?  A system designed to help folks connect better to the resources they need. Community Based Care Coordinators look at everything getting in the way of good health outcomes.  These barriers are identified and translated into pathways.  There are 20 core pathways:
  • Adult Education
  • Behavioral
  • Developmental Screening
  • Developmental Referral
  • Education
  • Employment
  • Family Planning
  • Health Insurance
  • Housing
  • Immunization Screening
  • Immunization Referral
  • Lead
  • Medical Home
  • Medical Referral
  • Medication Assessment
  • Medication Management
  • Postpartum
  • Pregnancy
  • Social Service Referral
  • Tobacco Cessation
• Each pathways can be very complex
• Pathways and progress are tracked electronically. 
• Pathways are completed when cm verifies it is complete.  Document failures, too.
• Community Based Care Coordinators receive at least 50% of payment from completing pathways.  A completed pathways means an identified risk factor has been successfully addressed or work was done but the risk factor was unable to be addressed. 

(I had to take a call from the Boss Man, so I missed a bit here. –ed.).

• Step 1 – Find – work with clients to determine Pathways – work on things the clients want to work on
• Step 2 – Treat – work through the decided on Pathways
• Step 3 – Measure – see if pathways is complete or if another treatment is needed
• Within one family alone, there could be 3 or more care coordinators working independently.  Pathways tries to help the family organize itself and centralize information, as well as not duplicate services
• Work to supplement services already being received.  For example, if you work with a pregnant woman, that person may not realize they eligible for maternity support services (Maternal Support Services, if you are reading this, come and present at a homeless provider meeting –ed.).  If you do a Maternal Support Services assessment – you get assigned a level of resources based on the level of risk.  Those unit are often used up in a few visits.  With better care coordination provided by Community Based Care Coordination, Maternal Support Services can use their units just for the medical piece, and pathways can do the other supports that aren’t medical.
• Within Pierce county, there are 4 care coordination agencies for pathways Community health workers 
  • Korean Women’s Association
  • Community Health Care
  • Sea Mar
  • HopeSparks
  • These Community Based Care Coordinators aren’t tied to specific agencies – they do work for agencies - but enter data in a centralized cloud based system.
  • Train Community Health Workers – they have an 8 week training with a practicum. 
• Care Coordination agencies had a short time to get good staff hired, and they did a great job. 
• Currently have 100 referrals for pregnant women.  Target is 250 at least.  That may seem like a lot, but nationally, the caseload for Community Health Workers is like 50. 
• Tacoma Pierce County Health Department – focused originally on areas with low birth weight.  Used other risk criteria – past low birthweight child, past drug or alcohol use to determine who to help.  Focus  on patients with high risk. 
• Can call or text 253-444-3070 to get resources (crappy photo of lovely flyer attached –ed).
• Pathways is a care tool – translates risk factor into pathways to take action to address them.  Measure based on what worked. 
• The community hub tracks the pathways – where all the data is stored.  Work to eliminate duplication – have a single location for referrals. 
• Attempt to move from current system where different providers don’t know what services are being provided.
• If a client signs an  ROI, we can show other agencies we are working with what the client is working on and the progress they are making. 
• Marybeth – what if the client isn’t happy with the referral to one agency they receive?  Can they switch?  Also, you mentioned outcome payments are based on completed pathways, how does that encourage good outcomes?  Liszet – reward is for work done even if there is no outcome. We can switch an agency they were referred to if a client doesn’t like working with an agency.  If an agency is a barrier, we can move them to a different agency.  We are trying to get good information about what works and what doesn’t work – part of the purpose of the ACH community voice council
• Patricia – is there support for terminating a pregnancy?  Lizette – yes, if that is the support they want we will work to supply it.
• Al – There is a lot of overlap between what the case managers in this room do and the work of the Community Health Worker.  How would could someone become a community health care worker? Liszet- this is still a trial project, and want to make sure it works before adding more target populations. 
• Questions – I Have a lady I discovered who is 5 months pregnant – they migrate around – not sure I’ll see her next week?  How to assist?  Lizette – we are focused on Pierce county – can help folks migrating in pierce county.  We’ll try to help someone stay in one place, and find out what they would need to get that.  Will work with them. 
• Kenny – Peer counselors? Liszet -Community health worker in this phase I program only work with pregnant women
• Charleen – just 4 zip codes or all county?  Lizette – it is all pierce county.
• Question – how long after deliver is there support?  Liszet – for 2 months after delivery. 
• Do you have a stock of housing?  Lizette – no, we do not have a stock of housing. 
• James – if you have a pregnant client – Maternal Support Services and Pathways are both great places to refer clients.