Care Coordination
Celebrating Two Years of the Central Ohio Pathways HUB
The month of March marked the two-year anniversary of The Central Ohio Pathways HUB (the HUB), a nationally certified care coordination model for Franklin and contiguous counties that is managed by the Healthcare Collaborative of Greater Columbus (HCGC). The HUB model is utilizing 11 care coordination agencies (CCAs) that employ over 40 Community Health Workers to assess medical, behavioral, and social risks for our most vulnerable neighbors and connect them with community resources to mitigate those risks. The HUB has served more than 2,500 clients, of which 80 percent represent minority or foreign-born populations.
Addressing Disparities Among Vulnerable Populations Amplified During Pandemic
While vulnerable populations disproportionately experience disparities and inequity, the COVID-19 pandemic has amplified disparities among underserved communities in the region and in communities where the HUB is currently serving clients. HUB CHWs have provided over 900 educations related to COVID-19 to their clients since the onset of the pandemic. There has been an exponential growth in education pathways regarding COVID-19 related measures, such as understanding stay-at-home orders, mask mandates, navigating telehealth appointments, and what to do if clients or their family members become ill. Now, more than ever, CHWs are finding themselves advising and connecting clients to important information on health insurance enrollment (including Medicaid), unemployment benefits, career education, food assistance, and guidance on attending prenatal and other preventative healthcare appointments.
“We are grateful to our local and state officials who have called for a renewed focus on racial, cultural, and economic disparity in light of how COVID-19 is disproportionately affecting people,” said Carrie Baker, HCGC President and CEO. “We are committed to providing the data necessary to increase equity, while simultaneously preparing our community health workers to support and protect our growing number of clients.”
In addition to educating clients, CHWs have also been working to educate and connect Central Ohio’s most vulnerable citizens with information on receiving a COVID-19 vaccination. At each encounter, CHWs are discussing the COVID vaccine with their client, providing evidence-based education to dispel unfounded myths, and assisting clients in finding a vaccine locations, appointments and transportation when needed.
Referrals from Community Providers and Organizations Based on Trust and Success
While Medicaid Managed Care referral partnerships remain steadfast and abundant, the HUB has built trust in the community over the past two years that has inspired several other community providers and organizations to begin referring at-risk, vulnerable members of the community into the HUB. Ohio State University Wexner Medical Center, OhioHealth, The Columbus Metropolitan Housing Authority, City Attorney Zach Klein’s theft diversion program, and Franklin County Public Health’s Centers for Disease Control Opioid Data to Action initiative have all formed partnerships with the HUB to connect at-risk individuals with care coordination with a CHW.
“Our referral partners recognize the value in providing evidence-based, proactive connection to care and services that can change the course of at-risk individuals lives. By referring for coordination services with the HUB, providers and organizations know that their own systems will run more efficiently, providing an organized, successful experience for their patients and clients. CHWs are trusted, reliable caretakers in their communities, and they work for some of the most incredible agencies in central Ohio, bravely navigating both before, during and after this pandemic. CHWs can not only help find, report, and decrease the spread of COVID-19, but also support clients hardest impacted by the pandemic to recover from the health, social and economic perspectives.” said HUB Executive Director, Jenelle Hoseus.
Since HCGC began managing the HUB in March of 2019, CHWs have made several impactful connections to care and services for some of the region’s most vulnerable citizens.
Here is what we have seen:
An average of 600 clients a month are served by CHWs in the HUB;
In two years of operation, the HUB has served over 2,500 people in central Ohio;
71.8% of Pathways that were opened by CHWs on behalf of their clients were successfully completed (over 11,000 total), resulting in over $450,000 being reimbursed by Medicaid Managed Care and then sent back out to participating local CCAs;
92% of babies born to Black or African American mothers in the HUB were born at a healthy birth weight, compared to INSERT Franklin County numbers;
95% of participants in the theft diversion program partnership with City Attorney Zach Klein have successfully completed the program, accepting connection to the care and services to set them a path to success and wellbeing rather than incarceration and/or fines.
“The HUB embodies possibility and hope. It’s infrastructure allows for intentionality and intimacy between client and CHW which is the life blood of the program. I was once in my client’s shoes – 3 ½ year ago I was a heroin addiction and living out of my car. My clients can see who and what I am today, yet know my story on where I was, and that breathes possibility and hope," said HUB CHW Matthew Demoulin who is employed by Franklin County Public Health, "The HUB Pathways allow me to live out a simple motto: To give back what was given to me. I had individuals show me a love and intentionality which allowed me to help myself out of a very dark hole. I try to do the same for my clients and the HUB Pathways gives me the platform to do so.”
