Care Coordination (Pathways HUB)

Program Overview

Physical health, behavioral health, and social support systems historically do not coordinate their services well. Numerous barriers prevent patients moving seamlessly from one service system to another. Community Based Care Coordination brings standardization and organization to care coordination services delivered in the CPAA region. The HUB is an evidence-based model to improving care coordination by working with care coordinators to identify high-risk individuals, complete a comprehensive health assessment, identify risk factors, and determine what standardized “pathways” a care coordinator should employ with the individual. By implementing this model and forming a HUB of providers, referral sources, and payers, the region can jointly prioritize the needs of specific populations. This structured approach to community-based care coordination is a strategy that helps leverage our limited resources to deliver whole-person care and become more effective and efficient at improving health outcomes. In addition, community-based care coordination helps simplify the complex web of services provided to individuals with complex needs, will lead to more effective services for patients, and will generate a new data set that will better inform HUB participants for continual quality improvement.

Top Metrics for Improvement

Metrics for this project are currently in draft form and are being updated by the Health Care Authority. The metrics under consideration include:

• Number of partners trained by focus area or pathway: projected vs. actual and cumulative
• Number of partners participating and number implementing each selected pathway
• % PCP in partnering provider organizations meeting PCMH requirement
• % partnering provider organizations using selected care management technology platform
• % partnering provider organizations sharing information (via HIE) to better coordinate care
• % of partnering provider organizations with staffing ratios equal or better than recommended
• Number of new patients with a care plan
• Total number of patients with an active care plan
• Mental Health Treatment Penetration (Broad Version)
• Outpatient Emergency Department Visits per 1000 member months
• Percent Homeless (Narrow definition)
• Plan All-Cause Readmission Rate (30 Days)
• Substance Use Disorder Treatment Penetration
• Follow-up After Discharge from ED for Mental Health
• Follow-up After Discharge from ED for Alcohol or Other Drug Dependence
• Follow-up After Hospitalization for Mental Illness
• Inpatient Hospital Utilization


• A Community HUB will be created to collaborate across organizations and to target specific populations to serve
• Care coordination services will be standardized and clients equitably distributed among Care Coordinating Agencies (CCA)
• Individuals and families in target populations will receive one single care coordinator when they enter the system
• Data will be standardized and centralized through the HUB and used to map patterns of need, access, and the most critical gaps in services to fill
• Outcome based payments will create a reliable marketplace where purchasers can easily value and acquire care coordination services

Evidence-Based Approach

This project area implements the Pathways Community HUB model developed by Dr. Sarah Redding in Ohio. The model has been successfully implemented across the United States and has demonstrated improved outcomes and savings in multiple settings. The research literature has documented specific positive outcomes with the at-risk pregnancy population, and Pathways implementation to serve a chronic disease population is currently being studied with promising initial results.


Behavioral Health Providers, Community-Based Social Service Organizations, Medicaid Managed Care Organizations, Pediatricians, Primary Care Providers, Public Health, Health Care Administrators

Transformation Timeline and Milestones

Project Work Group is working on:

1. Current state assessment
2. Identify Domain 1 strategies that support project
3. Finalize target populations and evidence-based approaches
4. Determine partnering providers
5. Complete implementation plans
6. Plan describing regional transition to fully-integrated managed care

Project Implementation in 2019, and scaling-up in 2020.

• CPAA will work with up to six Care Coordinating Agencies by the start of 2019 to implement the model
• CPAA will serve about 400 people in the first year of implementation
• CPAA will expand capacity throughout the Transformation to serve about 4,500 people by the end of the transformation period

Social Determinants of Health and Care Coordination

Care coordination services are an important aspect of care delivery because they connect people to resources that support the broader social determinants of health. The Pathways HUB model specifically assesses all aspects that contribute to wellness and provides standardized Pathways that help people access and obtain the help they need. Examples include education, employment, and housing. The Pathways model also emphasizes that clients should set their own goals and be supported by care coordinators. This means that services are not driven by organizational bottom lines, but the specific things that people need the most to make improvements in their own lives.

Project Area Contact

For more information, contact Michael O’Neill, Care Coordination Program Manager: