Care Coordination
Emerging Opportunities to Provide Care Coordination through the Central Ohio Pathways HUB
by Heidi Christman, Director of Communications, HCGC
Since January of this year, HCGC has been managing the Central Ohio Pathways HUB, a care coordination program that links the most at-risk populations in our region to services that address their social, economic, and both mental and physical health needs. We have seen great success in connecting clients with several services including insurance enrollment; establishing a medical home with a primary care physician; access to mental health services; addiction and cessation services for drugs, alcohol and nicotine; prenatal and postnatal care for new mothers and their babies; stable, affordable housing; reliable, coordinated transportation; chronic disease management; and various education opportunities regarding a plethora of subject matter including safe sleep for babies and insurance renewal requirements. Through the supervision of ten Care Coordination Agencies (CCAs), our HUB Community Health Workers (CHWs) have enrolled 387 clients in the HUB, with 251 of those individuals being currently active in the system. Those 387 clients have accounted for over 2,800 Pathways, or connections to the aforementioned and other care and services.
At just nine months under HCGC management and just seven months of actively accepting clients, we have seen great opportunity in how we deliver these services to the community. HUBs around the country, and certainly in the state of Ohio have typically been focused on Infant Mortality and efforts to decrease racial disparities in that space. The Central Ohio Pathways HUB has certainly continued that tradition. Since March of this year, our HUB has twenty nine closed Pregnancy Pathways resulting in thirty live births (one set of twins), and twenty five of those births resulted in healthy birthweight babies, including the set of twins. Nineteen of these babies were born to black mothers, six to white mothers, and the remainder were born to mothers of various racial and ethnic backgrounds.
We are proud of this work and plan to expand and improve upon it, and we have also seen great opportunity to utilize all twenty Pathways in other sectors of the population at large. We have been thrilled to share the HUB model with our partners in the Columbus City Attorney’s Office. Since June, City Attorney Zach Klein and his team have put in place a theft diversion pilot program, which allows petty theft offenders to enter the HUB at their first court appearance. If they complete the six-month program by showing progress and a will to engage, the offense is removed from their record. There are currently HUB 26 clients enrolled in this program. City Attorney Klein and the Columbus City Council awarded Central Ohio Pathways HUB $25,000 to cover the care of clients who are not eligible for Medicaid coverage, or, as we call those instances in the HUB, in-kind clients.
Another exciting partnership that we have established just in time for Breast Cancer Awareness Month is with the Susan G. Komen of Columbus Foundation. Komen of Columbus has provided our HUB with a $15,000 grant to provide breast health education and referrals for screening and treatment to women and men who are being seen by a CHW. These grant dollars will also fund in-kind clients who are not covered by Medicaid Managed Care.
Fifty percent of breast cancer deaths in black women in Columbus are found in five zip codes. There are great racial disparities in access to quality breast health screening and referral, and Komen sees the HUB model as a great way to start to help narrow those gaps in access. CHWs in the HUB have access to unique populations, some of which are in those five area codes that are disproportionately affected by lack of access to breast health services. Through this work, CHWs will educate both women and men on self-breast health awareness, encourage clients to assess risk, identify clients at risk and link to available resources, continue addressing the other needs and social determinants of health of clients at risk, and provide feedback to Komen about barriers or issues in the system. CHWs will officially begin providing these services on October 1st, and HCGC looks forward to supporting this important work in our community.
For more information on the Central Ohio Pathways HUB, please visit our website, hcgc.org, or contact the HUB Executive Director, Jenelle Hoseus at jenelle@hcgc.org.
