Elevate Health Celebrates Pathways Community HUB Second Anniversary

Our Pathways Community HUB Model is celebrating its second anniversary! We are proud and excited to reach this milestone, and also inspired by the health care workers and teams we’ve collaborated with in the last two years whose contributions have helped to make the Pathways Community HUB a success. We are grateful for your dedication, support and passion to help improve the health of our community.

Our Model

According to Health Affairs, every dollar invested in community health worker programs addressing unmet social needs has a $2.47 return on investment per dollar invested within the fiscal year. The Pathways Community HUB is an evidence-based model for care coordination engaging community health workers. This model provides community-based, culturally competent, and person-centered care coordination for vulnerable, traditionally under-served Medicaid populations. This approach promotes care coordination across the continuum of health services, ensuring that people with complex health needs are connected to the interventions and services to improve and manage their health.

Community health workers are at the front line serving as liaisons between health, wellness, and social services in our community. They are a key workforce to ease client access to services by possessing a deep understanding of the communities they serve. Community-based care coordinators who participate in the Pathways Community HUB model look at everything that is getting in the way of good health outcomes including access to health care, housing, employment, safety, and education.

Pathways Community HUB Programs We Offer

To meet the needs of our community, we incorporated feedback from community members to tailor our HUB model to fit the populations in need in Pierce County. We offer 20 different Pathways to support people in our community, including:

• Development Screening
• Developmental Referrals
• Social Service Referral
• Education
• Medical Referral
• Pregnancy
• Medical Home
• Postpartum
• Health Insurance
• Tobacco Cessation
• Medication Assessment
• Housing
• Behavioral Health
• Family Planning
• Employment
• Adult Learning
• Medication Management
• Lead Education
• Immunization Screening
• Immunization Referral

In addition, we established two population focused programs under the Pathways model, both of which are nationally-certified programs. The first, Get Well with Wellness First, addresses Medicaid clients who have multiple chronic disease or health issues and need information or assistance around navigating the health system, including employment, educational opportunities and additional services. The second, Passage2Motherhood, connects Medicaid clients experiencing high-risk pregnancies with resources and assistance for social services, health insurance, medical home, and other services.

Successes in 2019

• The top three chronic conditions the Pathways programs served were depression, anxiety disorder, and chronic pain.
• The highest volume of completed Pathways, which indicates those with the highest needs were for:
  • Social Service Referral (37%);
  • Education (31%);
  • and Medical Referral (29%).

Moments We Celebrated Along the Way

• In January of 2017, we engaged in an interactive Pathways 101 session with Sarah Redding, MD, and Founder of the Pathways Model of Care Coordination Sustainability and Director of the Pathways Community Hub Institute (PCHI). Dr. Redding shared her experience on how a community can successfully achieve the benefits of a Pathways Community HUB Model based on the needs and requirements within their own community.
• In March of 2018, we launched an eight-week training course for community health workers provided by the Foundation for Healthy Generations and Washington State Department of Health; we continue to provide trainings on the Pathways model for community health workers in our community.
• Passage2Motherhood and Wellness First have resulted in many success stories and impacted the lives of people in Pierce County.
• In December 2019, Elevate Health’s Pathways Community HUB (HUB) was recognized and certified by the Pathways Community HUB Institute (PCHI) with a Level-I designation making it the first of its kind to be certified in Washington state. This certification reflects how we meet the national standards for quality community care coordination services and are committed to pursuing excellence. Certification is also a value-add to promote the community health worker workforce and bring a clearer definition around their scope in contract to other healthcare workforce members.

Our Incredible Partners

We could not have reached this milestone without the support of our partners in Pierce County. We are grateful to each of them and for their continued collaboration.

• CHI Franciscan, a comprehensive health care system, offering expert care from highly skilled providers at locations throughout the Seattle and Tacoma areas.
• Community Health Care, a private, non-profit organization with a mission to provide the highest quality healthcare with compassionate and accessible service for all.
• Hope Sparks Family Services, is a recognized leader in Pierce County in behavioral health, early intervention, kinship care, home visiting, eating recovery and parent education.
• Korean Women’s Association of Washington, a nonprofit organization creating safe and accessible programs that best serve our communities.
• Tacoma- Pierce County Health Department, dedicated to protecting and improving the health of all people and places in Pierce County.
• Sea Mar Community Health Centers, a Washington public benefit corporation that provides comprehensive health, housing and cultural services to diverse communities, specializing in services to all ethnicities and populations.

If you or someone you know could benefit from the Pathways Community HUB, email care@elevatehealth.org for more information.