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Research to Reform: Achieving Health System Change (Text Version)

On September 14, 2009, Sherry E. Gray made this presentation at the 2009 Annual Conference.


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Research to Reform: Achieving Health System Change
AHRQ 2009 Annual Conference
September 13-16, 2009

Progress of a Learning Network: Working to Reduce Disparities by Improving Access to Care 

Monday, September 14, 2009
Sherry E. Gray, M.A.
Director: Rural and Urban Access to Health
St. Vincent Health

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Focusing on Outcomes

The Pathway Model:

1. Identify Individual at Risk +
2. Confirm Evidence-based Intervention =
3. Measure Outcome Health and Cost Savings 

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The Pathways Model

Identify areas of greatest need

geomapping, analyzing existing databases, needs assessments

Establish a community hub

centralized community group: communication; data collection; tracks services provided by community health workers

Develop Pathways

start with "agreed upon" outcome; build steps from desired end-point; capture steps to completion; capture barriers and successes for intervention/ problem-solving 

connect funding mechanisms to outcomes vs. activity-based reimbursement

Identify and train community health workers

Implement established Pathways until the outcome is accomplished

Conduct ongoing quality assurance and evaluation

monitor the progress and outcomes

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 "Ohâ€â€another program!"

Pathways are NOT:

  • Part of a "canned program"
  • Simple and quick solutions to complex problems
  • Built/developed in a "silo" and then "introduced" to other agencies, providers, programs, funders, for adoption and implementation
  • A fad

Pathways ARE:
  • A proven care coordination model
  • Community based
  • Adaptable to a variety of "at-risk" populations
  • Evidence-based interventions at the grassroots level
  • Used to create outcome-based accountability and reimbursement vs. activity-based reimbursement

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The Learning Network and Pathways

The Pathways Model (PM) is a strategy to establish measurable positive outcomes for populations most at risk in the community, develop action steps to accomplish those outcomes, and track progress at the level of individuals. The purpose of this Learning Network is to bring together sites that have expressed interest in implementing this innovative model in the communities. Through this Learning Network, the sites have an opportunity to share information on their individual settings, learn the strategies and techniques needed to implement the Pathways Model, and benefit from each others' experiences. 

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RUAH History

  • RUAH Partnership initiated: 2000
    • SV Health
      • In patient, Out patient, Community Based Care
    • Indiana Health Centers, Inc.
      • Federally Qualified Health Care Center (FQHC)
    • Health and Hospital Corporation of Marion County
      • County Health Department
    • ADVANTAGE Health Plans, Inc.
      • Insurance Provider (public and private plans)
    • Butler College of Pharmacy, later added
      • PharmD students
      • Pharmaceutical Assistance Program (PAP) Consultation
      • Project Management/Oversight
    • Community Interface Groups: local partner groups responsible for program implementation.
      • Health centers, health departments, physician offices, civic groups, and health, human and social service agencies
  • Funded by HRSA, Ascension Health from 2001-2005
  • Sustained through local hospital funding and captured reimbursement through enrollment efforts 

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Current Service Areas

  • Clinton County
    • St.Vincent Frankfort *
  • Howard County *
    • St. Joseph Hospital
  • Madison County
    • St. Vincent Mercy
    • Progress of a Learning Network:
    • Working to Reduce Disparities by Improving Access to Care
    • Saint John's Health System
  • Randolph County *
    • St.Vincent Randolph
  • Clay County
    • St.Vincent Clay
  • Jennings County
    • St.Vincent Jennings
  • Fountain and Warren Counties
    • St.Vincent Williamsport

* Original CAP grant program sites

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RUAH Today


To connect our friends, family, and neighbors to a comprehensive, integrated delivery network of health, human and social services resulting in improved access and removal of barriers to needed resources.

Meaning and Mission:

The word ruah, in yiddish means "Breath of Life".

The Goal?

... to breathe new life into a dying health care system trying to serve our most vulnerable community members

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Focus Areas:

  • Health Access Workersâ€â€"client advocates & system navigators
  • Pharmacyâ€â€access to low or no cost drugs through Medication Access Workers (MAC's)
  • Creation of "Medical Homes" for the underserved
  • Access to Specialty Care for the underserved
  • Program enrollment (financial resource review and application assistance)
  • Reduction of inappropriate Emergency Room utilization
  • Assistance with supportive social services ("wrap around")
  • Diversityâ€â€translation of core documents, medical interpretation, key signage, development of diversity councils, LEP Assessment
  • Sustainability

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Program Outcomes: (November '02-June '09)

  • Four community programs expand to Eight community programs
  • Additional private sector funding obtained
    • Anthem Foundation
  • 29,767 client encounters
  • 59,081 referrals, including
    • Medical Home appointments
    • Government program applications (Medicaid & SCHIP, etc.)
  • $18.2 million worth of low/no cost drugs provided
  • 800+ HIP applications = $ 2+ million captured reimbursement

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Sound Good?

  • RUAH produces good work
    • Interaction (patients, clients, providers)
    • Connectivity/integration (community agencies and acute care facilities/providers)
    • Activity (doing lots of things "to and for" people)
    • Access (primary care home assignments/specialty care)
    • Reimbursement (received funding not previously captured)

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  • Did any of it work?
    • Intuitively it appears that it does
  • How do we know?
    • Did the activities produce:
      • Lower A1C values for Diabetics?
      • Better birth outcomes for high risk pregnancies?
      • Lower blood pressure and decreased cardiac risks?
      • Manage asthma symptoms and decrease ER visits and hospitalizations?

1. The answer? We don't know.
2. The question: How do we find out? Find a way to connect the work to measurable outcomes that is both simple and real...

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Pathway Implementation (our "beta site")

  • Work with Madison County and Saint John's Hospital

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  • Maintain all current RUAH access work
  • Build a local CKF Coalition
  • Host a high level Stakeholder meeting
  • Develop "behind the scene" infrastructure support: IT, agreements, etc.
  • Hold the initial Madison County Community HUB Pathway development summit
  • Implement the Pathways developed by the HUB
  • Evaluation and "Fine tuning"

Slide 15

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How's it going?

Stay tuned... we are still on the pathway

Current as of December 2009
Internet Citation: Research to Reform: Achieving Health System Change (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD.


The information on this page is archived and provided for reference purposes only.


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