Steps of Care Coordination
Find.
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The Bridges to Wellness HUB receives the referral and assigns it to a Community Health Worker (CHW). The CHW engages with the individual and families in the community. A referral can be through our referral partners, contracted Medicaid plans, or self-referrals.
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Enroll and Assess.
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The referred individuals will meet with a CHW, either in their home or in a community setting to enroll into the program. The CHW will complete a comprehensive assessment to identify the participants health and service needs.​
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Coordinate.
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The CHW will develop a plan of care for the individual by opening standardized pathways. The CHW will assist the participant on community resources while educating the individuals on self- advocacy.
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Track Metrics.
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The CHW will continue to meet with their participants at least once a month while their needs are being identified. Pathways will close as connections are being made.
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Reimbursement.​
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The Bridges to Wellness staff audit and invoice completed Pathways each month, sending them to a Medicaid managed care plan for reimbursement that is then send back to the CCA that employees the CHW.
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Our Partner Care Coordination Agencies
The HUB, by definition is a neutral entity that does not directly provide care coordination services. Our Care Coordination Agencies (CCA) join the Bridges to Wellness HUB to access a common system by referring and connecting clients with various community resources, social services, and even healthcare providers. While being a contracted partner, our CCAs agree to use the PCHI® Model for data collection in a standardized way – including data collection tools, standard pathways to track risk factors, and standard reports. The CCAs then assign Community Health Workers (CHW's) to serve clients in the community and enroll them to Bridges to Wellness Program.
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National HUB certification through the Pathways Community HUB Institute (PCHI HUB Institute) is becoming a greater focus and requirement of funders and policymakers.
Future Partners
Belmont | Carroll | Coshocton | Guernsey | Harrison | Holmes | Tuscarawas | Monroe | Muskingum | Noble | Washington
If you are interested in being a Partner Care Coordination Agency in one of the above counties, please contact:
Paige Dugan, Bridges to Wellness HUB Director at paige@accesstusc.org
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"My experience with Madison was so nice, she helped me fill out paperwork, and get baby supplies for my son, among many other things. She was very nice, kind, and wonderful. She supported me and my family and continues to do so. Through the support of her family and Madison, Juana also stated that it was a common message from her mother and Madison that, "You have to win to achieve what you want".
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Juana, Participant Testimony