The Texas Managed Care Organization (MCO) Social Determinants of Health (SDOH) Learning Collaborative continued our work last month with an exploration of the Pathways Community HUB Institute (PCHI).
The PCHI® Model helps communities come together to support their under-resourced residents and to improve health and well-being. The champion of this model of care is the Community Health Worker (CHW). The Pathways Community HUB (PCH) works in partnership with community-based organizations, agencies, providers and other stakeholders to develop a robust network of community resources. This partnership and network allow the PCH to serve as a centralized location for individuals to access community resources with the assistance of a CHW. The CHW helps the individual navigate the network and address their needs through care coordination and a whole person approach.
The PCHI® Model provides training and tools for CHWs to identify risk factors and work towards eliminating those risks one by one. A unique characteristic of this model is it provides the infrastructure to track risk factors from identification through mitigation and link payment directly to outcomes. In Ohio, a Medicaid health plan found that high-risk mothers without PCH intervention were 1.6x more likely to deliver a baby needing special care and newborns born to high-risk mothers enrolled in PCH had a PMPM cost savings of $403 during the first year of life when compared to those born to mothers without the same intervention.
To help demonstrate the impact of this model in Texas, the Episcopal Health Foundation is currently funding an evaluation of the Pathway Community HUB in San Antonio. Today there are 4 PCHs in Texas in various stages of implementation:
Brazos Healthy Communities (Texas A&M University Health Center and Project Unity in Brazos County with a targeted launch date of December 2022): Brazos Healthy Communities will focus on pregnant women with anxiety and/or mild depression and plans partner with community organizations that serve pregnant women with multiple pregnancies.
Harris County Pathways Community HUB (The Network of Behavioral Health Providers (NBHP) in Harris County with a targeted launch date of September 2022). Harris County PCH’s target population will be current Medicaid recipients or Medicaid-eligible adults who have behavioral health risk factors, mental illness or a substance use disorder. The NBHP will lead the Harris County PCH which is a collaboration of more than 40 mental and behavioral health provider in the greater Houston area. To date, Harris County PCH has successfully recruited five full time state certified CHWs.
Williamson County Accountable Communities of Health (United Way of Greater Austin with a launch date of March 2023). The Williamson County PCH will target pregnant moms and families with young children and is currently partnering with Health District, Lone Star Circle of Care, Georgetown Health Foundation, and Ascension-Seton to build network of trusted care coordination agencies across the county. Williamson County seeks to recruit four CHWs by their go-live date.
Grow Healthy Together Pathways HUB (Bexar County and launched in July 2018). Grow Healthy Together Pathways HUB is available for all underserved individuals in the community. Over the past 4 years, the Bexar County PCH has successfully contracted with five care coordination agencies, recruited 14 CHWs and secured contracts and funding from multiple health plans and local entities.
The Learning Collaborative members are now exploring ways this model can be integrated into Texas’ Medicaid managed care programs. Since CHWs are not providers that currently bill for Medicaid services and the PCHs are not necessarily providing services that tie to a specific reimbursable Medicaid service or code, the question becomes - how are contracts executed and how are these services reimbursed?
The model is currently operating in 17 states and most states categorize this work as administrative costs or service coordination/case management. These programs can also be used as a value-add benefit for members, or a health plan can execute a value-based contract with the PCH. Conversations during the Learning Collaborative have led down the path of exploring the opportunity to categorize this work as Quality Improvement (QI). For activities that are not covered medical or dental services, the Code of Federal Regulations (42 CFR § 438.8(e)(3)) allows certain expenses for activities that are designed to improve health care quality to be included in the numerator of the medical loss ratio for managed care plans in Medicaid.
Over the next several months the MCO SDOH Learning Collaborative members will continue to review options for integrating this model into Medicaid managed care programs and learn more about how Pathways Community HUBs can improve the overall health of communities in Texas. You can learn more about the PCHI® Model here.
About the Episcopal Health Foundation: EHF is based in Houston and was founded in 2013 by the Episcopal Diocese of Texas upon the transfer of St. Luke’s Episcopal Health System.Bishop Andy Doyle of the Episcopal Diocese of Texas led the effort to use the more than $1 billion in proceeds to start a foundation that would reshape the way the Episcopal Church engages the community and change the way we think about health in Texas. EHF chose to focus on improving community health, rather than just health care, because the opportunity for good health starts long before you need to see a doctor. Health systems need scalable solutions to address non-medical factors that impact health. EHF was created as a community-based philanthropy to spark transformative change within the diocese’s 57-county service area that serves more than 11 million Texans.
About the MCO SDOH Learning Collaborative: The Learning Collaborative is a partnership of the Texas Association of Health Plans, Texas Association of Community Health Plans, the Texas Health & Human Services Commission, and the Center for Health Care Strategies. It is made possible through support from the Episcopal Health Foundation. The learning collaborative is helping Texas Medicaid MCOs understand effective strategies for addressing the social needs of Medicaid beneficiaries and support the development and implementation of interventions to address social needs. The learning collaborative, which includes regular in-person and virtual meetings,is enabling Texas’ Medicaid MCOs to learn from one another and from leading-edge health plan and provider innovators across the nation.