Community-based Care Coordination

When the NCACH selected Community-Based Care Coordination as one of its Medicaid Transformation Projects in 2017, the Pathways Community HUB model was the only evidence-based model ACHs could choose from. Our ACH opted to contract out the implementation of this model, and Action Health Partners boldly and passionately stepped up to the challenge. Implementing a Pathways Community HUB in our region was a huge undertaking, but one that built on their successful track record with the Health Home program.

The pilot launched in Moses Lake in October 2018, and we conducted a rapid-cycle evaluation to learn about successes and challenges, including barriers that delayed expansion. In late 2019, the Health Care Authority indicated that, while they remained supportive of community-based care coordination, they were prioritizing Health Homes as the program for high-risk Medicaid beneficiaries and that future funding for Pathways HUB would have to come from local and regional partners. All of these factors contributed to our decision in early 2020 to discontinue implementation of the Pathways Community HUB model.

NCACH remains committed to enhancing community-based care coordination across the region during the remainder of the Medicaid Transformation. We submitted a Project Plan Modification Request , which the Health Care Authority approved  in November 2020. Moving forward, our overarching goal is to strengthen the network of community‐based care coordination programs across the North Central region so that the network is more cohesive and better able to respond to the needs of North Central residents, especially those with significant behavioral health needs, those utilizing acute healthcare services frequently, and those struggling with incarceration.

We understand community‐based care coordination as a relational and person‐centered approach designed to improve access to and coordination of supports for individuals and families in struggle. It involves face‐to‐face visits with clients at a place of their choosing, and the deliberate organization of comprehensive social and health care services done in partnership with clients to facilitate their whole person health. Because it is broader than medical care coordination or case management, it relies on a community‐based workforce focused on problem solving, advocating and communicating on behalf of and with their clients, across many systems and organizations.