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NEON Pathways Community Hub

Summary 
  • Need: Connect individuals to services that address health barriers.
  • Intervention: A pay-for-outcomes model utilizing Community Health Workers who help provide community members with tools to address needs associated with improving health.
  • Results: Trained Community Health Workers help patients navigate the healthcare and social service systems and provide education about community healthcare resources.
Description

Pathways Community Hub logo The Pathways Community Hub, managed by Northeast Oregon Network (NEON), utilizes trained Community Health Workers (CHWs) to help at-risk patients navigate health and social services resources in the Oregon counties of Union, Baker, Wallowa, and Malheur.

The Pathways Community Hub model operates under the over-arching theme of improving patient health, bettering healthcare, and lowering costs by improving the quality of care.

Northeast Oregon Network logo NEON has contracts with different organizations, or Contracted Hub Organizations (CHOs), who employ and provide salary support for the CHWs. NEON serves as a neutral entity in this program, neither acting as a service provider or an employer. Instead, it pays the CHOs for pathways successfully completed by CHWs.

First identifying high-risk patients, CHWs assess patient needs and determine which of the seven evidence-based pathways will be most suitable. These pathways focus on key areas of health and social services which might require the most assistance to navigate. The final goal is improving local health outcomes by connecting individuals with needed resources.

Once a pathway is completed, payment is generated to the employing CHW organization as compensation for work completed. Using a community-based data tracking system, all payments to Hub partners are based on successfully completed pathways.

This evidence-based compensation model has shown to be the most efficient and valuable payment structure for the Pathways Community Hub model. The payment model awards organizations that work effectively and efficiently. As partners, they can earn more money based on the amount of success achieved.

The community-based data tracking system monitors patient outcomes and serves as the invoicing system for outcomes model pay. Throughout this program, the Hub allows for close tracking of an individual’s health journey, making it an efficient way to target patient health outcomes and improvements.

To help the Hub in achieving its goals, a leadership team was formed consisting of partner organizations and other stakeholders from the four-county area. This group determined what pathways should be used, and created a guide that governs the functions and operations of the Hub. They also oversee continuing high-level decision-making for the Pathways Community Hub.

Both uninsured and underinsured patients under current care by a health care provider can enroll in the program in order to streamline their healthcare experience utilizing the Pathways Community Hub’s centralized infrastructure. This infrastructure helps avoid repeat lab tests, doctor visits, and similar duplication. By joining this program, patients and providers both will benefit from cost savings associated with preventive care methods, and from close monitoring of patient needs. Several partners have decreased emergency department visits by using CHWs.

The infrastructure for this program was developed in 2012 from Centers for Disease Control grant. Starting in October of 2014, the program moved into the launch phase with operational funding coming from a Federal Office of Rural Health Policy Network Development grant. Outcome payments came from funding through the Meyer Memorial Foundation

Services offered

This program focuses on helping community members successfully navigate through seven evidence-based pathways:

  • Health insurance coverage
  • Medical homes
  • Medical referrals
  • Medication assessments
  • Medication management
  • Social service referrals
  • Tobacco cessation

Organizations that staff CHWs and contract with NEON benefit from:

  • Increased community networking
  • Increased awareness of local organizations providing health and social services
  • Collaborative work between organizations to positively impact health in the community
  • Increased revenue through outcomes payments
Results

Since the program’s inception, NEON has contracted with 7 CHOs and 12 CHWs to give community members the tools and resources to address their specific healthcare needs. CHWs have provided public education on health and social services, such as:

  • Prenatal care
  • Immunizations
  • Chronic disease management
  • Parenting education
  • Housing
  • Food
  • Clothing
  • Diabetes prevention
Barriers

The main challenges surrounding this program include:

  • Sustainable funding sources
  • Payment models based on outcomes, no immediate payment are given
  • Providing program value education to organizations and potential payers
Replication

In order to implement a similar program in other communities, it is important to:

  • Seek out start-up funding for initial CHWs salaries
  • Work with the community to hire CHWs
  • Form an active leadership team with community organizations involved in the decision-making process
  • Be mindful that the program a slow implementation process
Contact Information
Eric Griffith, Pathways Community Hub Coordinator
Northeast Oregon Network
541.624.5101 ext. 3
egriffith@neonoregon.org
Topics
Community health workers
Health screening
Human services
Reimbursement and payment models
Uninsured and underinsured
Wellness, health promotion, and disease prevention
States served
Oregon
Date added
May 11, 2015
Date updated or reviewed
June 13, 2017

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.