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Welcome to CHAP
  September 1, 2010 |     Author admin

Connecting those at risk to Care

Community Health Access Project (CHAP)

CHAP is focused on reaching those at greatest risk and assuring they connect to primary care and
prevention services. We recognize the interlocking issues of social determinants of health and
also assist with connection to housing, food clothing, adult education and employment. We are
excited to see many of our clients work forward from high risk pregnancy and homelessness to a
healthy baby, stable housing and sustainable employment.

CHAP focuses on three principals – Find, Treat and Measure. We work within our own
community and a network of communities across Ohio and the United states to develop
evaluation strategies that specifically target high risk individuals. Using the Pathways model at
risk individuals are supported through a process that identifies the health and social service needs
and assures their connection to critical interventions.

It is recognized that an at risk 17 year old
who is homeless and without prenatal
care has both health andsocial service
concerns that are intrinsically linked and
must be addressed in parallel. Her health
is also critical to her unborn child.

The expenses that will occur if these
issues are not addressed are currently
highlighted in our national health care
expense and health outcome reports. We
haveby far the greatest expense for health care in the developed world and the worst health

CHAP works with Community Health Workers, Social Workers, Nursesand Physicians to
achieve the goal of connection tocare. We see the packages of evidence based interventions in
primary care, obstetrical care, immunizations, dietary education and many more as critical, on
the shelf ready to be delivered. Our job is to reach into the forgotten urban housing complexes
and isolated rural house trailers helping provide a kind and competent guide to assure those at
                                                        risk connect to the packages.

                                                       Pathways as a model for care coordination
                                                       assures that the individual actually
                                                       connects to care as part of the payment
                                                       structure. Payment contracts utilizing
                                                       Pathways are at work in great variety
                                                       connecting payment to confirmed
                                                       connection to care and positive
                                                       outcomes. The model of payment is far
                                                       different than the current program based
                                                       purchase of the health care system.
                                                       Pathways draws from the success and
                                                       wisdom of private business that currently
                                                       has    many      highly effective and
                                                       accountable strategies for not only
developing great products but also assurance that those products go to where they are needed.
UPS does not get paid unless the package is delivered. An at risk individual today is less likely to
connect to basic prevention and treatment then they were 10 years ago and the health care budget
has more than doubled in that time. Where is the assurance that those in greatest need are being
reached and served effectively? We can reach those at greatest risk and assure their connection to
critical prevention and treatment. Ours the most wealthy nation can also have the best health
outcomes at an accountable cost.

Health Care Reform – Care Coordination Critical to Fundamental Improvement

Not all Americans have equal opportunities to be healthy. Conditions such as inadequate
education and low income interact with unstable housing and unsafe neighborhoods to produce
poor health in individuals and communities. These social determinants of health exert a powerful
influence on health disparities—may be even more powerful than medical care or genetics.
Moreover poor access to health care services worsens the harmful effects of these social
conditions. Access to health care through effective care coordination provides a strategy to
addressing these determinants of health by assuring barriers to care are address and individuals
are connected to critical prevention and treatment services.

Amber is a 17 year old pregnant mother who lives with her 15 month old child in a dangerous
housing complex in Columbus Ohio. She is eligible but has not signed up for insurance. She has
no transportation. The eviction notice on the card table creates a different set of priorities that she
and her 15 month old have to face. She needs to be found by a care coordinator, who is effective,
engaged and supportive in ensuring that she reaches preventive medical care as well as suitable
housing, gets back to her GED and eventually employment. The resources available to Amber
involve multiple agencies, and tracking that coordination of care across these agencies requires
multiple metrics that cross multiple sectors.

Our nation has the best specific health care interventions in the world. People travel from across
the globe to receive heart surgery etc. These specific interventions and their value must be
protected. Interventions with scientific basis for substantial improvement including prenatal care,
parenting training, nutrition training for parents of young children and many more, have great
potential to improve health and reduce cost. The problem is in our system, our delivery
system. Those who need these interventions the most don’t get them and ultimately connect to
care of the most expensive and catastrophic type starting out in the back of an Ambulance.

Our current system will come right to your door if you have an expensive health care
disaster. We are almost unreachable if you would like to receive a preventive treatment. We need
focus, measures and contracts that hold the system accountable to find, treat and measure the
outcome. Systems that not only reach the rich as they do now but also reach those more complex
and high risk patients currently avoided by the American Health Care system.

Private business is successful or out of business based on the same type of product and delivery
accountability needed within the health care system. Policy makers and founders must stop
simply purchasing programs and start examining the specific products and assurance of delivery
for critical health interventions that hold hope for dramatic disparity reduction and cost savings.

The network of communities currently utilizing the Pathways model represent a beginning early
structure demonstrating this work and this type of accountability and contracting can be done
using existing infrastructure. Contracts are in place the work across the community system of
care assuring those at greatest risk are found and assured to be connected. Duplication is
eliminated and payment is tied to both connection to care and affirmed healthy outcomes. The
Pathways manual and the Draft Community Hub Manual offers more detail.

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