March 24, 2022 – CommonSpirit Health is launching a new partnership with Pathways Community HUB Institute (PCHI), a national nonprofit that has developed an effective model to help communities work together to support their underserved populations. Through the creation of a robust infrastructure for community-based care coordination, the PCHI Model solves many of the challenges communities face in their efforts to improve the health of people who are struggling, and it complements CommonSpirit’s other health equity initiatives.
The Pathways Community HUB Institute outcome-based payment model brings together everyone involved in community health–hospitals, clinics, health plans, community-based organizations, community health workers, and others–to identify individuals with modifiable risk factors–medical, social, behavioral–and connect them to services, track outcomes and contract with payers that directly tie payment back to those outcomes.
With this model, local community health workers engage with families to connect them to social and medical services to remove barriers to health. Barriers to health, or risk factors, are translated into 21 standardized Pathways. Each Pathway represents the steps needed to remove the barrier or risk, which can include lack of housing or employment or inadequate access to certain medical and behavioral health services. A Pathway is completed when the risk factor has been removed.
Because the work is tracked electronically and outcomes are standardized, these Pathways measure success at overcoming risks and helping people receive what they need. This information can also help communities understand what is and isn’t working so improvements can be made. As research shows that Black women are more likely to deliver a baby preterm or with a low birth weight, due in part to social and economic barriers, the model may help close outcome gaps for these high risk mothers and their children. In an early pilot in Ohio, the model demonstrated that high-risk mothers without PCHI intervention were 1.55 times more likely to deliver a baby needing special care.
CommonSpirit’s partnership with PCHI is an extension of its existing use of community health workers to help patients manage the many and varied risks and overcome barriers. For example, an HIV patient was treated for pneumonia at a CommonSpirit hospital, where staff discovered that it had been years since the patient had seen an HIV specialist or taken medication. Hospital staff introduced the patient to a community health worker, who gained his trust and was able to help him get back on medication, find a primary care doctor, secure advice and support from a nutritionist, and line up a range of counseling services for medication adherence and other self care. Using the PCHI model, the community health worker continues to partner with the patient for ongoing health improvement.