Southeast Ohio Community HUB Mobile Health Technology

The Southeast Ohio Community HUB Mobile Health Technology (MHT) project involves a partnership between the Ohio Department of Medicaid (ODM), the Government Resource Center (GRC), and the Integrating Professionals for Appalachian Children (IPAC) to develop standardized programmatic measures and provide new resources to improve the Pathways Community HUB Model by implementing, testing, and evaluating the use of mobile technology for care coordination.

The Community HUB pregnancy pathway was designed to identify populations of pregnant women at risk for poor birth outcomes and connect them to the appropriate health and social services to improve their clinical outcomes and reduce both costs and health disparities. Specifically, care coordinators conduct outreach in high-risk populations and link pregnant Medicaid beneficiaries and those pregnant women eligible for Medicaid to needed services and resources. The goal is to improve birth outcomes in this population by facilitating early initiation of prenatal care and receipt of other needed social and medical services for those who may otherwise not receive adequate care during pregnancy.

IPAC Overview

IPAC operates the Southeast Ohio Community HUB, also known as the PATHWAYS Program, an eight-county community based wellness project with a model of integrated care coordination that fosters collaborations with social service and health organizations in the region. The program, which serves pregnant women and families with young children has received approximately 250 referrals in little more than a year. Caseworkers and nurses ensure that women attend prenatal appointments, assist with counseling, smoking cessation, housing, and much more. As of February 2014, the program holds a rate of 89% of enrolled mothers giving birth to healthy weight babies.

Mobile Health Technology Integration

Duet Health, the mobile health technology vendor that was selected through a competitive bidding process in state fiscal year 2015 for the initial work will continue the development and testing of the flexibility of the mobile health technology by implementing it in a rural community. GRC, Duet Health, and IPAC will work collaboratively to adapt the original design to meet the business rules of the Southeast Ohio Community HUB, and implement a reporting module that allows for flexible report creation by administrative users and data export to common dataset formats. A standard prenatal risk assessment data collection form, as adopted by ODM and the Ohio Medicaid managed care plans will be implemented for optional use by the Southeast Ohio Community HUB.

This project has the potential to significantly increase the quality of care and decrease the disparities in birth outcomes for Ohio Medicaid’s pregnant women. With better tools to support communication and care coordination, the targeted high-risk women will be appropriately linked with timely services and care interventions critical to their prenatal maternal, social and behavioral service needs. This linkage will ultimately lead to improved birth outcomes and Medicaid cost savings.