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Appendix: Brief Descriptions of Existing Community Hubs

The following are brief descriptions of community hubs that have been developed.

Pathways Community Health Access Project (CHAP), Mansfield, OH

This hub serves high-risk pregnant women, focusing on geographic areas where 30 percent of low birth weight deliveries occur. The hub's primary mission is to increase the number of healthy weight births and to promote healthy pregnancies. This is done by securing access to needed medical and support services for at-risk women, including insurance, food stamps, transportation, employment, and housing. Key outcome measures include the program's impact on birth weights, prenatal visits, and miscarriages. More information is available at http://www.cjaonline.net/Communities/OH_AccessProject.htm External Link.

Lucas County Initiative To Improve Birth Outcomes, Toledo, OH

This hub serves high-risk, low-income pregnant women, with most clients coming from ZIP Codes where the prevalence of low birth weight babies is three times the national average. Most clients are African American. The hub's primary mission is to increase the number of healthy weight births and to promote healthy pregnancies. This is done by securing access to needed medical and support services for at-risk women, including insurance, transportation, and housing. Key outcome measures include the program's impact on birth weights, prenatal visits, and miscarriages. More information is available at http://www.hcno.org/health-improvement-initiatives/pathways.html External Link.

Access El Dorado (ACCEL), El Dorado County, CA

The hub's primary mission is to ensure access to care for children under the age of 19. Key outcome measures include the program's impact on newborn and well-child visits to primary care physicians, immunizations, mental health pediatric consultations, and access to specialty consultations, as well as obtaining and retaining health insurance. More information is available a http://www.acceledc.org/ External Link

The Pathways to Health Project - The Health Partners Initiative (HPI), Lincoln, NE

This hub serves low-income minorities in a geographic region that is home to more than 265,000 residents, 7 percent of whom live below the Federal Poverty Level (FPL). The hub's primary mission is to improve the management of asthma by improving access to care and needed support services, including insurance, transportation, and child care. Key outcome measures include the program's impact on blood glucose levels, ED utilization, healthy birth outcomes, and miscarriages.

Project Access Dallas, Dallas, TX

This hub served Dallas County residents who were insured and had an income below 200 percent of FPL. Many clients were African American or Hispanic. The hub's primary mission was to enhance access to screenings, preventive health services, and diabetes and depression care, and to reduce inappropriate care. Support services included helping to secure access to food stamps, transportation, housing, and child care. Key outcome measures included the program's impact on blood glucose levels, cholesterol, systolic blood pressure, smoking, aspirin use, cancer screenings, ED utilization, and Beck Scores (a measure of levels of depression).

Care Coordination Programs of CHOICE Regional Health Network (CRHN), Olympia, WA

CHOICE Regional Health Network is a nonprofit community health collaborative formed in 1995 that serves a five-county, primarily rural area of Southwest Washington State. CHOICE serves the region's low-income population (below 250 percent of FPL), providing language and culturally appropriate services to Hispanic and Southeast Asian individuals. Roughly one-third of clients are Hispanic, and most do not speak English. Specific client services have evolved in response to member organizations? needs and priorities, service needs, and programmatic opportunities relevant to health and as a result of the maturation of close working relationships between health and social service providers. As possible within funding and priorities, CHOICE provides clients with assistance in accessing a wide range of resources, including subsidized health care coverage, connection with an affordable medical home, specific health screening and treatment services, prescription assistance, health education, enrollment in food stamps, and screening/referrals for other needs related to food, housing, and income security. CHOICE also provides more intensive care coordination with specific referred populations, including individuals exhibiting high and inappropriate ED utilization and clients of free mental health and chronic care clinics. Key outcomes measures include the program's impact on cancer screenings, diabetes referrals/visits, and ED utilization. More information is available at http://crhn.org/home.asp External Link.

Rural and Urban Access to Health (RUAH), Indianapolis, IN

This hub serves individuals with incomes below 200 percent of FPL in a largely Hispanic community of just over 100,000 residents. The hub's primary mission is to increase access to needed medical and social services (including insurance, transportation, and child care) and to reduce inappropriate care. Key outcome measures include the program's impact on chronic disease management and ED utilization. More information is available at http://www.stvincent.org/Community-Connections/Programs/Advocacy-Support-Programs/Rural-and-Urban-Access-to-Health.aspx External Link.

Central Oklahoma Project Access (COPA) Community Health Worker/Health Care Navigator Program, Oklahoma City, OK

This hub serves homeless, underserved, and uninsured populations, particularly individuals with chronic illnesses such as diabetes, hypertension, and cardiovascular disease. Roughly 20 percent of clients do not have insurance, while 16 percent live below the FPL. Just over 15 percent are African American, while 11 percent are Hispanic. The hub's primary mission is to reduce disparities for high-risk individuals by ensuring access to appropriate management of chronic diseases and availability of support services, including insurance, food stamps, transportation, and child care. Key outcome measures include the program's impact on blood glucose levels, ED utilization, diabetes visits, and physician visits.

Healthy Moms & Babes, Cincinnati, OH

A seasoned community outreach agency, Healthy Moms & Babes serves high-risk pregnant women in the Cincinnati area, a region with just under 850,000 residents. Roughly 45 percent of those served live below 300 percent of FPL, and just under one-quarter (24 percent) are African American. The hub's primary mission is to increase the number of healthy birth weight deliveries by securing access to needed medical care and social support services, including insurance, food stamps, transportation, employment, and housing. To that end, the agency serves as the administrative coordinator and lead organization for a pregnancy pathway operated in conjunction with four other social service and public health agencies. As of May 31, 2009, 247 clients were enrolled in the pathway. Key outcome measures include the program's impact on birth weights, prenatal visits, and miscarriages and connection to a medical home for mother and infant. The hub and the pregnancy pathway represent critical service components of the Greater Cincinnati Access Health 100 Initiative and are the first phase of a regional care coordination hub. The hub will expand to serve uninsured, Medicaid, and underinsured populations who earn up to 300 percent of FPL and who experience poor health outcomes due to selected chronic diseases, including hypertension, diabetes, and asthma. More information is available at http://www.healthymomsandbabes.org External Link.

Rio Arriba County Pathways Pilot Project, Rio Arriba, NM

This hub, which includes a broad array of stakeholders (including providers), serves pregnant women with substance abuse problems. The goals are to increase the number of healthy weight births, reduce substance abuse during pregnancy, and promote breastfeeding for at least 60 days. The hub works to increase access to food stamps, transportation, and housing. Key outcomes include the program's impact on birth weight, prenatal visits, and attendance at parenting workshops. Hub activities are funded through a State grant.

The Muskegon Community Health Project, Muskegon, MI

This hub serves recently released prisoners from county prisons, primarily men between the ages of 26 and 45; 60 percent of clients served are African American. The hub strives to reduce recidivism rates, use of illegal drugs, and infectious diseases. The hub also helps better manage chronic diseases by facilitating access to pharmaceutical assistance, insurance, food stamps, housing, and career services. Key outcomes include the program's impact on recidivism rates, incidence of hepatitis and HIV, physician visits, and medication compliance. More information will be available at http://www.mchp.org External Link.

The Access Project Medical Debt Resolution Program, Boston, MA

This hub serves individuals with medical debt by seeking to enhance access to insurance and other assistance programs. Key outcomes include the program's impact on medical debt and insurance enrollment. More information is available at http://www.accessproject.org/medical.html External Link.

The Coalition of Community Health Clinics Access and Referral Program, Portland, OR

This hub serves homeless, low-income, and uninsured individuals earning under 200 percent of FPL; the goal is to enhance access to medical and social services, including primary care visits, food stamps, transportation, and housing. Key outcomes include the program's impact on well visits to primary care physicians.

Pathways of Bernalillo County, Albuquerque, NM

This hub serve homeless and low-income individuals in Bernalillo County, New Mexico. The goal is to enhance access to medical and social services, including primary care visits, food stamps, transportation, and housing. Key outcomes include the program's impact on well visits to primary care physicians. More information is available at http://hsc.unm.edu/community/pathways/ External Link.

HealthMatters of Central Oregon, Bend, OR

This hub serves children between 0 and 18 years of age in central Oregon. The goal is to increase access to medical and social services, including well visits to primary care physicians, immunizations, food stamps, transportation, and housing.

Mid-America Regional Council, Kansas City, MO

This hub serves low-income individuals; the goal is to increase access to medical and social services, including well visits to primary care physicians, immunizations, food stamps, transportation, and housing. More information is available at http://www.marc.org External Link.

Case Studies of Organizations Implementing Pathways

The Agency for Healthcare Research and Quality Innovations Exchange includes eight profiles (similar to case studies) of organizations that have successfully implemented pathways. Each write-up includes a capsule summary of the program, a description of the problem addressed, a descriptive summary of key program elements and the results achieved to date, background on the context and impetus for the program, a review of key planning and development steps, and a discussion of considerations for would-be adopters, including lessons related to getting started and sustaining the program. Links to each of these profiles are provided below: