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Charting A Pathway To Better Health
Publication

Charting A Pathway To Better Health

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This article details how Toledo and other communities nationwide are implementing a new approach to care coordination to reach patients where they live, rooted in the belief that a meticulous and coordinated attack on an individual’s social determinants of health led by a trained, local community health worker can mitigate many negative social determinants and produce better health outcomes for people at high risk.

The Pathways HUB model differs from other social determinants models on at least two important counts:

  • It manages its clients with community health workers who come from the same neighborhoods as the people they serve
  • The model’s financial framework is premised on a monetary incentive that is realized by care coordination agencies—that is, the community health workers’ employers—when HUB clients achieve measurable, positive outcomes in a host of factors, both large and small.

There are twenty Pathways in the HUB model, ranging from housing to postpartum services and a behavioral health referral. There are broad Pathways such as social services, which includes twenty-five subcategories or tools such as a telephone, food stability, or a plan to start tackling medical debt. Each Pathway has an outcome, a specific metric that must be completed before the community health worker’s employer is paid—typically by the patient’s managed care plan or a government entity such as a local department of health.

This article is part of a series on transforming health systems published with support from the Robert Wood Johnson Foundation.

Components of Alignment

Financing Icon Financing
Shared Purpose Icon Shared Purpose

Author Organization

Health Affairs

Publication Date

12.03.2018

Topic Area

Complex Care
Social Needs
Brief

Intermediary Organizations Are Urgently Needed to Assist in Modernizing Public Health and Addressing the Drivers of Health in the United States

This issue brief describes the different roles intermediaries can play; provides examples of where they have been used in practice; and identifies the risks, benefits, and possible innovations of intermediaries as well as policy approaches that might facilitate their appropriate use.

Publication

“More Than Just Giving Them a Piece of Paper”: Interviews with Primary Care on Social Needs Referrals to Community-Based Organizations

This publication characterizes referrals to community-based organizations by primary care practices, which are increasingly being used by healthcare organizations to invest in social care.

Publication

Revising the Foundational Public Health Services in 2022

This publication provides a framework outlining the unique responsibilities of governmental public health and can be used to explain the vital role of governmental public health in a thriving community; identify capacity and resource gaps; determine the cost for assuring foundational activities; and justify funding needs

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