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R.E.A.L. Solutions recap: How the Pathway Hub Model is addressing infant mortality
Infant mortality is of grave concern throughout our country, and particularly in Ohio, where they are in the bottom two of all states.

NRHI hosted the first R.E.A.L. Solutions (Results & Evidence for Action-based Learning) virtual event on Thursday, September 26, 2019. We were joined by presenters Carrie Baker, President & CEO of The Health Collaborative of Greater Columbus (HCGC), and by Rita Horwitz, President and CEO of Better Health Partnership (BHP), and in this session, explored implementation of the Pathways Community HUB Model to address social determinants of health (SDoH) and specifically impacts of SDoH on infant mortality. 


R.E.A.L. Solutions offers an opportunity for members across our network to display their expertise, results, and evidence, and to also workshop barriers to implementation through case presentation and audience discussion. The aim is to increase connections, create space for shared learning, and to continue to support solutions to tough problems.


Carrie lead off by saying infant mortality is of grave concern throughout our country, and particularly in Ohio, where they are in the bottom two of all states. In fact, in Franklin County, Ohio, 150 babies die each year before their first birthday. Additionally, she said that black babies are dying at nearly three times the rate of white babies. These tragic statistics match up with eight specific neighborhoods in the county, where they face high crime, low performing schools, lack of infrastructure and services as well as little access to healthy food.


As a solution-oriented organization, HCGC was ready to adopt the Pathways Community HUB Model. In the early phase, they quickly decided they had to respond, knowing that 80 percent of a person’s wellbeing and needs relate to SDoH. The Pathways Community HUB Model, built on an evidence base, links direct services in healthcare settings to care coordination in clinical settings, as well as care coordination in communities. This is largely made possible by community health workers (CHWs) who are well-versed in care coordination, community services, insurance, and other helpful components of treating a whole person. The CHWs interact one-on-one with clients at least once a month and begin to open up pathways of care. The average client in HCGC’s HUB has 8.5 pathways, and they currently have 375 individuals participating. The program is growing quickly and is seeing success.


Why are Regional Health Improvement Collaboratives (RHICs) well positioned to implement this model? Carrie answered this question with the following: RHICs are neutral conveners, non-profit organizations, able to provide technical assistance, and have strong community relationships. However, building will among community stakeholders has its challenges particularly when the project raises concerns with competition, redundancy of services, patient attribution, and scope of practice. This message came through Rita’s case presentation. BHP is beginning the work to stand up their own HUB, and though energized by the model, they face some barriers. The key considerations from stakeholders are valid, yet per Carrie and other NRHI members’ recommendations, the obstacles can likely be overcome. Here is a summary of the recommendations:

  • Use data. It is powerful, can trigger action, and provides opportunity to present solutions
  • Look for partnership opportunities and be willing to offer services to partners that can address their concerns
  • Build trust through transparency

Also noteworthy is the work that Rita and team have underway as it helps showcase how to get started. Here are a few examples:

  • Connect with individual community agencies
  • Engage other HUBs to understand lessons learned and how to have success
  • Work with community leaders (such as First Year Cleveland)
  • Look for policy opportunities

Having the opportunity to partner across regions, to learn and address barriers is a display of the commitment and passion we have within NRHI’s network. We invite you to reach out with questions and to get involved in future R.E.A.L. Solutions.


Join us for the next R.E.A.L. Solutions session, focusing on Eliminating Low Value Care. Members can register here: https://nrhi.zoom.us/meeting/register/11c77986faf4334166858a512be5123a