Pathways HUB Community Action

by Community Action Akron Summit

Region 5 · Akron, OH
https://www.ca-akron.org/

Child Health • Infant Mortality • Maternal Health

Overview

Pathways Community HUB is an evidenced-based, care coordination model that Community Action Akron Summit has been replicating since 2016. Community Action was the first CAP in the country and in Ohio to be certified nationally as a Pathways Community HUB (source: https://pchi-hub.com/hubs/). The HUB serves as the fiscal and administrative agent that provides training for CHWs, data management, grant writing and Medicaid billing and compliance. The HUB creates a network of agencies, hospital systems, FQHCs, nonprofit and government organizations to address the complex, multi-system needs of individuals in a community.

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Local Need Addressed

The local need that the HUB addresses is infant mortality.

In 2015, Ohio was 48th in the country for Black infant mortality (ranking as the near worst state in the United States). In Summit County, Black infants are two to three times more likely to die that white, non- Hispanic infants.
In 2015, Black infant mortality rate in Summit County was 15 per 1,000 exceeding that of the county’s and state’s overall infant mortality rate.
In Summit County, clusters of neighbors represented not only the highest rates for infant mortality, but also the highest proportion of persons living below 100% of the federal poverty line.

The costs of preterm and low birth weight infants to a community is extraordinary.

March of Dimes estimates that the cost of prematurity is $41,116 per infant with a lifetime cost of over $300,000 per infant based on gestational age of delivery (Waitzman and Jalali, 2019).
Between 2006 and 2015, 192 or 42.9% of the infant deaths were attributed to prematurity. The rise in premature births, especially among African American mothers, has contributed to the high numbers of infant mortality in Black families.

Transformative Impact

Systemically tracks and collects information about community needs, barriers and challenges provides the data for community transformation

Reduces health disparities and creates a shared approach to community care coordination through a centralized data system.

Empowers families to be in the center of their care while partnership with a Community Health Worker and aligns the systems and services to support that family under the umbrella of the HUB network

Evidence-Based Outcomes

The Hub model has demonstrated evidence in reducing Black infant mortality and improving health outcomes in the community (Alley et al, 2016). There has been research published about the model’s return on investment (Buckeye Health Plan, 2018; Redding et al, 2015; Ziegler et al, 2015) when the model is implemented to fidelity. The model has been endorsed by Agency on Healthcare Research and Quality.

Customer Voice

The implementation of the Hub has been co-designed by CHWs, community partners, and customers of the services. The Hub receives regular input about processes and services from monthly CHW meetings. Hub staff collect feedback from customers formally on a quarterly basis through customer service surveys. The customer rates their interactions with the CHW and other service information. The data and feedback are reviewed frequently by Hub staff and shared with CA Board on a monthly basis.

Equity Lens

The goal of the Pathways HUB is to identify and provide services to those individuals with the greatest needs and health disparities. The model systematically addresses individuals’ needs and risks while identifying barriers to care and resources in communities. All of this information is tracked on one of 20 pathways providing community level data about gaps in resources and services. Additionally, there has been published research demonstrating the model’s effectiveness in reducing health disparities and advancing equity. One area where this has been documented is in black infant mortality, one of the focused of the Hub in Summit County. The community health worker workforce is another component of the advancement of equity.