Community-based Care Coordination

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.

Increase your awareness and understanding of regional community-based care coordination efforts in our region by exploring the resources and spotlights below. (Click each bullet to be directed to additional resources)

Foundational Community Supports in North Central WA

Health Home Program in North Central WA

Partner Spotlight: Communities in Schools of North Central Washington

April 14th, 2021|Comments Off on Partner Spotlight: Communities in Schools of North Central Washington

Join NCACH as we shine a light on some of the amazing work our incredible partners are doing! This month, NCACH staffer, Caroline Tillier, got to connect with Communities in Schools of North Central Washington [...]

Picking up where we left off: Community-based Care Coordination

January 4th, 2021|Comments Off on Picking up where we left off: Community-based Care Coordination

December 22, 2020 -- It’s hard to believe 9 months have passed since we announced the discontinuation of our Pathways HUB pilot. We learned a lot about what it takes to stand up and resource [...]

A statement from NCACH regarding the Pathways Community HUB

March 3rd, 2020|Comments Off on A statement from NCACH regarding the Pathways Community HUB

March 03, 2020 -- After much consideration, the North Central Accountable Community of Health (NCACH) has decided to discontinue the contract held with Action Health Partners to implement the Pathways Community HUB. This decision was [...]

Bridging the gaps between the community and the clinic… Pathways Community HUB

November 2nd, 2018|Comments Off on Bridging the gaps between the community and the clinic… Pathways Community HUB

  (Photo - Risk Factors Addressed to Achieve Wellness - Pathways Community HUB Institute, all rights reserved) In June 2018, the North Central Accountable Community of Health’s Governing Board designated Community Choice (dba Action Health [...]

NCACH selects lead agency for Pathways Community HUB

June 5th, 2018|Comments Off on NCACH selects lead agency for Pathways Community HUB

FOR IMMEDIATE RELEASE -- June 5, 2018 On Monday, June 4, the North Central Accountable Community of Health's Governing Board appointed local organization, Community Choice, to serve as the Pathways Community HUB. After reviewing and [...]

Care Coordination Workgroup releases RFP for Pathways HUB

March 28th, 2018|Comments Off on Care Coordination Workgroup releases RFP for Pathways HUB

For immediate release --- March 28, 2018 North Central Accountable Community of Health The Care Coordination Workgroup within NCACH, tasked with overseeing the adoption and implementation of Community-Based Care Coordination, has released a Request for [...]

NCACH’s Community-based Care Coordination staff support:

Caroline Tillier, Project Manager

Email Caroline ││ 509-886-6431