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 
.
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/lucas_initiative.htm .
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/
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 serves Dallas County residents who are
insured and have an income below 200 percent of FPL. Many clients are African
American or Hispanic. The hub's primary mission is to enhance access to
screenings, preventive health services, and diabetes and depression care, and
to reduce inappropriate care. Support services include helping to secure access
to food stamps, transportation, housing, and child care. Key outcome measures
include 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). More information is available
at https://www.projectaccess.info/html/about.html .
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/www/index.html .
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 .
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. More information is
available at http://www.centralokpa.org/ .
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 .
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 (under construction at the time of publication.).
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 .
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://www.berncohealthcouncil.org/ .
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. More information is available at http://www.healthmattersco.org/ .
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 .
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:
