Community hubs ensure better care for the most vulnerable

Research Activities, June 2011, No. 370

It wasn't just because a few people cared that three patients with different but equally dire circumstances were helped. There's another reason these individuals received the medical and social services they needed... again, again, and again.

In Ohio, a community health worker discovered a young woman living in a dilapidated apartment building. When the worker convinced the woman to seek medical care, they were both surprised to learn she was in her second trimester and pregnant with triplets. Later in the pregnancy when the woman wanted to leave the hospital against medical advice, the health worker convinced her to stay. All three babies were born so healthy, they didn't need a ventilator, a typical need for triplets.

In Indiana, an unemployed father of an adolescent was promised a job in manufacturing. When the job didn't materialize, the father thought he could pick up his former career as a truck driver. But high blood pressure kept him from being hired and fueled fears he would lose his son. On the night his blood pressure spiked so high he thought he was having a heart attack, he went to the emergency room. A health access worker referred him to a federally qualified health care center and helped him get his blood pressure under control. The man was not only hired, he could care for his son.

In Oklahoma, a homeless man with diabetes was showing up in the emergency room once or twice a week for 6 months. He wanted more than medical care; he wanted socialization. By putting him on a pathway for the local clinic to become his medical home for care—and comfort—his emergency room visits dropped to only twice during the next 6 months.

Community hubs

These patients are part of community "hubs" that coordinate the delivery of health care and social services for the most vulnerable Americans. These hubs have the infrastructure to connect at-risk individuals to health and social services, while avoiding duplication of services.

Some hubs focus on high-risk pregnant women. Others care only for children. One serves recently released prisoners. All focus on people at risk, providing quality care while working to eliminate duplication and disparities.

Three principles guide community hubs:

  • Find: Identify those at greatest risk.
  • Treat: Ensure treatment through evidence-based interventions and evaluate their impact.
  • Measure: Document and evaluate benchmarks and final outcomes.

These principles are the driving force behind 16 hubs in 10 States that participate in the Community Care Coordination Learning Network, sponsored by the Agency for Healthcare Research and Quality (AHRQ)'s Health Care Innovations Exchange, which connects people with innovations and solutions that improve care and reduce disparities.

Through the Learning Network, representatives from each community hub share ideas, stories, and strategies with each other on a formal and informal basis. The Network is led by Mark Redding, M.D., a pediatrician in Mansfield, Ohio, and an advocate for the underserved. "Five percent of the population uses 50 percent of our health care resources, and those most at risk are often the hardest to serve," Redding told Research Activities. "This is a national emergency."

Caring for the most vulnerable can get complicated and Redding knows it. "An amazing amount of work goes on. I know when a patient comes through my door, it may have taken 20 hours of work to get her here." But the payoff is huge when babies are born healthy, excessive emergency room visits are avoided, and patients get the care they need. "We want to see things like diabetic education and immunizations be like packages on a shelf—within reach for everyone," he says.


Redding and his wife, Sarah Redding, M.D., executive director of the Children's Community Health Access Project (CHAP), cofounded the pathways model that hubs use. "Basically, a pathway is a measurement tool or metric focused on achievable outcomes," explains Sarah Redding. Pathways can address education, depression, prenatal care, housing, and more. An individual may have many pathways. A pathway is only complete when an identified problem is solved.

Key to the pathways is community care coordinators who navigate care and advocate for patients. They may be nurses, social workers, or community health workers. "It doesn't matter who does it," says Sarah Redding. It does matter what they do and how they do it. "Each pathway is tracked. The model is rather simple, but even though it's not rocket science, it can be messed up." That's why measurement is so important. But even then, she admits, "Measurement can only get you so far. You have to take that information and do something better."

"The pathways allow for local innovation, but ultimately they hold people accountable," explains Mark Redding. He proposes that payment for completed pathways be directly linked to outcomes. "One of our Medicaid managed care organizations looked at our patients who received care coordination from 2007 to 2009 and found that our NICU [neonatal intensive care unit] costs for pregnant members only increased by a nickel," Sarah Redding explains. "This shows how connecting those most at risk with care adds up to real cost savings."

At Health Care Access Now, which stretches across nine counties in southwestern Ohio and northern Kentucky, executive director and Learning Exchange member Judith Warren, M.P.H., puts the pathways model in action for outcomes that affect high-risk pregnant women and adults who frequent hospital emergency departments. Warren says, "As we struggle with budget cuts, this type of structure helps us reduce duplication, improve outcomes, and simplify contracts."

Laura Brennan, M.S.W., Learning Exchange member and senior manager of CareOregon, says, "No matter what we do within the clinic walls, until we reach out and coordinate and address psychological and social factors, we're never going to meet our quality standards or improve the health of our members." This can be particularly challenging, since CareOregon provides translation for patients who speak nearly 20 different languages and are from even more cultures, notes Brennan. "We have a triple aim of improving the health of the population, bending the cost curve, and improving the quality of care."

Learning Network members stay connected. "We're not competitive, but we don't always like to admit what doesn't work," says Sherry Gray, M.A., Learning Exchange member. "We ask each other, 'What did you guys do? How do you do this?' We all do a lot with very little money." Gray is director of a community hub that serves homeless, underserved, and uninsured populations in Indiana called Rural and Urban Access to Health or RUAH. She says, "The acronym in Yiddish means 'breath of life.' We're breathing life into the system for real benefits that everyone can feel good about."

Where are they now?

In Ohio, the triplets are both healthy and in school. In Indiana, the truck driver recently was interested in making a donation to the program that helped him. And in Oklahoma, Mary Overall, M.S.N., director of health systems and compliance for Central Oklahoma, says even though they didn't completely end the homeless man's use of the emergency room, the reduction was "incredible." She says, "When we can put pathways in place, we'll have positive outcomes."

Editor's note: Connecting Those at Risk to Care, a guide to building community hubs, is available online at Printed copies are also available free of charge by calling the AHRQ Clearinghouse at 800-358-9295 or sending an Email to Ask for publication number 09(10)-0088.

Page last reviewed June 2011
Internet Citation: Community hubs ensure better care for the most vulnerable: Research Activities, June 2011, No. 370. June 2011. Agency for Healthcare Research and Quality, Rockville, MD.