The Central Ohio Pathways HUB Begins Participation in the Diabetes Self-Management Education (DSME) Program

By: Jenelle Hoseus, Chief of Policy and Partnerships, Health Impact Ohio & Chief Operating Officer, Central Ohio Pathways HUB

The Central Ohio Pathways HUB has been, since its inception, working with the Medicaid Managed Care Plans and other partners to showcase how the HUB model, when used to fidelity, can truly impact the health and well-being of our neighbors.

In an acknowledgment of the Ohio Department of Medicaid’s vested interest in positively impacting the health of all Ohioans through requirements on improvement in member outcomes from the plans, the HUB has consistently offered to participate in potential pilot projects that would allow for additional supports for success.

In 2021, there were initial conversations with the Managed Care Plans in the State around how we might be able to best support them in accomplishing these goals for improving outcomes in our community. This dialogue was a helpful starting point, but was put on hold temporarily to allow for additional supports for COVID-related efforts.

In the spring of 2022, the dialogue restarted and efforts became focused on chronic conditions – specifically, interest in diabetes management. It became clear that we needed a particular form of intervention to examine, and the consensus amongst the partners, including the Ohio Department of Medicaid, was that we should evaluate the impact of Community Health Workers (CHWs) to engage with clients, educate them on diabetes management options, and eventually, attempt to support clients to participate in Diabetes Self-Management Education (DSME).

Diabetes Self-Management Education programs offer hands-on training for individuals with diabetes – educating them on ways they themselves can be in the driver’s seat to bettering their health outcomes. They learn concepts around nutrition, exercise, the importance of A1c testing, and more. It also becomes a support system of other individuals having similar lived experiences and barriers.

We know that CHWs are incredible at reaching out to individuals in a meaningful way, which is critical for this work. Additionally, we know that if an individual has diabetes and is learning about all of these methods to bettering their own health outcomes, that a CHW may play a very critical role in supporting them to be able to access healthy food, exercise options, and anything else required for them – related to their diabetes, or any other forms of assistance that will give them the ability feel supported in being able to focus on bettering their health.

The Managed Care Plans have been working with us for approximately a month. They are doing internal reviews for members who have encountered data that reflects uncontrolled A1c. They are sending us cold referrals, where our CHW for this project will reach out to them to engage them and see if they would be interested in the HUB model. They are also sending us warm referrals where their teams have already engaged the clients to see if there is interest in participating in this effort as well.

All of these clients will be supported to accomplish any goals they may have with their CHW; all will be educated about DSME and, if they’re open to it, will be supported in participating in a DSME program.

The pilot itself is a two-month pilot, although the clients can work with the CHW for as long as they’d prefer and find benefit in the work. At the end of the two months, the HUB will be sending data around the engagement with both the cold referrals and warm referrals, how many clients enroll, how many are educated on DSME, participate in DSME programming, and any other potential gaps our CHW is able to address during their experience with the client.

This opportunity is a unique one for the HUB. We truly hope it’s the beginning of many opportunities moving forward, but more importantly, we find it to be a wonderful way to showcase the importance of the work that CHWs do for our clients, but also the importance of the work they do for the community and State. Impacting these critical chronic conditions spaces, HEDIS metrics, and more – CHWs are a vital link to how we move the needle in many forms of health outcomes – most importantly, improving the lives and well-being of Ohioans across the Central Ohio region, the State, and potentially the country.