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Score Card Pilot Results. Sarah A. Redding, MD, MPH Executive Director Community Health Access Project Mansfield, Ohio. Pathway Model: A Tool to Measure Outcomes. Target Population Engage those at greatest risk . 1 - Find. Confirm connection to evidence-based intervention. 2 - Treat.
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Score Card Pilot Results Sarah A. Redding, MD, MPH Executive Director Community Health Access Project Mansfield, Ohio
Pathway Model: A Tool to Measure Outcomes Target PopulationEngage those at greatest risk 1 - Find Confirm connection to evidence-based intervention 2 - Treat 3 - Measure Measure the Outcome
Client’s Perspective Health Social From the client’s perspective, social issues are as important as health issues. Both must be addressed.
Example – Pregnancy Pathway Initiation Step Defined “at risk” pregnant women engaged and enrolled in care coordination Identify/enroll at risk Care Coordination $ • Determine and document barriers: • Insurance Status • Transportation • Prenatal Care Evidence -based Intervention $ Prenatal care provider established First and ongoing prenatal visits confirmed $ Completion Step Healthy baby > 5 pounds, 8 ounces (2500 grams) Measureable Outcome
Central Registration – Agencies as a Team Mental Health Community HUB Schools Community- based agency County agency Hospital Primary Health Home Health Department State- funded outreach program • One Care Coordinator One Outcome (Pathway) • No duplication • Measurable results, tied to funding
Participating CCCLN Members • Albuquerque, New Mexico • Central Oregon • Dallas, Texas • Indianapolis, Indiana • Ohio: • Cincinnati • Mansfield • Toledo