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The Community Health Access Project
Richland, Knox and Franklin Counties, Ohio

Community Size:
Richland County. – Focus on two urban census tracts
Knox County - Focus on Appalachian, and Amish population spanning the eastern half of the County
Franklin County. – serves two urban census tracts within inner city Columbus Ohio.
Program started: 1999

Overview & Structure
The Community Health Access Project (CHAP) began as a community based outreach program in Richland County Ohio in 1999. The CHAP program expanded to rural Knox County in February 2000 and to inner city Columbus in 2001.

CHAP employs trains and supports Community Health Workers (CHWs) to reach out to their community helping at risk individuals overcome barriers to health and social services.

CHAP has been working with The Ohio Department of Health as a partner in the HCAP (spell out) grant. CHAP developed college level CHW training that has now been used to train over 200 individuals across the state. The CHAP program based this beginning CHW curriculum on experience with a similar program in Alaska, which had a tremendous impact on infant mortality and birth outcomes, particularly in economically disadvantaged communities. Integrated with the training and outcome focus is the outcome production model of "Pathways". Pathways allow health and social services to utilize an outcome production methodology to increase accountability and overall production of positive health and social outcomes. Pathways specifically identify a problem or issue that a family is facing and works through independent steps to a measurable successful outcome. Through the grant, four programs, representing twelve community based outreach sites, have adopted the Pathways approach to outcome production.

Features:
CHAP has utilized specific geomapping of outcomes to identify areas with the greatest need for positive outcomes. For example, in Richland County Ohio, birth certificates were reviewed for a period of five years to identify areas most at risk. Two small census tracts were found to have the highest concentration of low birth weight in the county. Pregnant women from these census tracts had a 24% rate of low birth weight (more than three times the overall county average). CHAP went to the churches and other local organizations to identify community members who were willing and capable of reaching out to this at risk community. College level CHW training was provided and the CHWs were sent out to find and assist pregnant women. Transportation, cultural differences, insurance and other barriers were identified and eliminated for expectant mothers. (For example, it was found that prenatal and pediatric physicians were located only a few miles away, but transportation by bus was more than 4 hours round trip, due to transfers, etc.)

Pathways - developed by CHAP - are a standardized methodology for improving health outcomes and was developed and implemented in collaboration with medical, social and community based providers. The system of Pathways assists in identifying those who need help the most, and then serves as a guide though social and medical service steps with a complete focus on achieving the positive outcome. For example, in the Immunization Pathway, if a child is identified in the community as being behind on immunizations, there may be a lack of insurance, medical provider, transportation and understanding as to why immunizations are important for the child’s health. Each of these steps and the agencies involved with these steps are linked together in a common outcome production tool/Pathway which will not be credited as completed until the child has had the immunizations and they are confirmed to be up-to-date. In this methodology critical social services as well as medical services are linked together in a common accountable outcome production tool - Pathways.

Pathways, allow health and social services to utilize outcome production methodology to increase accountability, and overall production of positive health and social outcomes. The Pathways approach can be integrated county-wide and across multiple agencies, allowing outcome production accountability at the county level.

This model of accountability has now gone county-wide in Richland County, making Richland Ohio’s first outcome production/accountability focused county.

CHAP has contracted with Jobs and Family Services to increase specific outcomes – and payment is not received until the outcomes are produced.

Outcomes:

• Utilizing Pathways and the care coordination services of CHWs, CHAP has demonstrated an 83% reduction in low birth weight for enrolled high risk women identified within the high risk census tracts of Richland County.
   
• CHAP has demonstrated the production of more than 7000 positive outcomes/Pathways for immunization, lead, truancy, chemical dependency, employment and others
   
• CHAP is working with the Ohio Department of Jobs and Family Services to show the cost savings potential of this model.
   
• CHAP is comparing birth outcomes and infant medical costs during the first year of life for economically disadvantaged women who have received preventive based Pathways interventions versus those who have not.
   
• Increased focus on achieved outcomes holds potential for the removal of disparities and significant cost savings though prevention.
   
• Public funds are used to buy specific health, social, educational, and employment services with measurable results.
   
• The model of Pathways demonstrates focus of allocations precisely on target populations and their needs as identified by census tract: constituents get the exact services they need with results.
   
• Pathways Tracks service barriers for quick analysis and disparity elimination.
   
• The Community Health Worker model provides a welfare-to-work approach supplying jobs within low-income communities.
   
• The Community Health Worker profession was signed into law as a new profession in the state of Ohio as part of Ohio’s budget bill July 2003. Through this landmark legislation CHWs will credentialed under the Ohio Board of Nursing.

Eligibility/number served:
The focus of CHAP services has been pregnant women and children. CHAP provides assistance to teenagers and adults with health access, and case management for education and employment. CHAP has served more than 5000 clients since beginning in 1999. CHAP has completed more than 7000 Pathways/positive health or social outcomes, since implementing the Pathways model in July of 2000.

Financing/Costs:
CHAP is primarily funded by the Osteopathic Heritage Foundations, the Department of Jobs and Family Services, and other grants and contracts.

Our primary costs are salaries for the CHWs. Due to safety issues two CHWs are sent out on each home visit. The cost - including administrative costs - to intensively case manage a pregnant or other high risk client for one year is approximately $1000. Using prevention of LBW as one example, CHAP has significantly reduced the rate of LBW for the clients served. In the most severe cases, one LBW baby can represent millions in completely preventable medical expenses.

Lessons Learned:
If outcomes are to improve and spending decrease the fundamental structure of the health and social system must change. We must define the health and social outcomes which are needed and hold each part of the system accountable for producing these outcomes. Pathways is a beginning and proven methodology to do this. Community Health Workers provide a key part of the outcome production process by serving to link economically disadvantaged, culturally isolated individuals to the health and social service system.

Contact
Mark Redding – reddingmark@att.net
Phone – 419-525-2555
www.chap-ohio.org

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