The Ross County Pathways HUB works to connect patients and providers for better overall health of the larger community. We understand that there are multiple factors that contribute to an individual’s health, including social determinants like culture, race, income, and education level. Our community has many vulnerable and high-risk individuals who are seeking care and assistance from hundreds of medical, behavioral health, education, employment, and social service organizations. We hope to streamline the process, connecting information for all stakeholders who are trying to impact the healthcare experience in our community.
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Ross County highlighted in NACCHO’s Stories from the Field
The article showcases RCHD’s collaboration with NACCHO and the CDC to implement the Advancing Health Equity in Cardiovascular Disease Prevention Efforts grant program that was awarded to RCHD earlier this year.
Pathways HUB Community Health Worker, Johnna Miller is featured in the article.
How it Works
Create specific protocols and checklists to standardize work, require greater accountability, and use for payment. These checklists incorporate multiple functionalities to help address the wide variety of circumstances at-risk individuals may face.
Provides a single point of contact for individuals/families. Coordinators understand all pathways through a common set of credentials (Certified Community Health Workers); agencies receive payment for pathways coordination services based on effectiveness of performance through ability to connect clients to services.
Shared Referral Infrastructure
Common system used by multiple community providers that allows identifiable client data to be used to refer a client to another organization. Allows for high quality referrals between pathways coordination providers and social service providers.
Funding from government, health care, and private philanthropy are needed to ensure pathways coordination occurs for all people. Payments are made when pathways are completed, or at agreed-upon milestones.
Community Health Workers (CHWs) serve as partners, advocates, and coaches for their clients and work to identify health needs and risks. Each risk is then translated into a pathway—including unmet needs for transportation, housing, and more—and tracked through completion in an electronic database.
- Social services
- Medical referral
- Medical home