Partners in Care: How HUBS, CHWs, Health Plans and Others Built Ohio’s Care Coordination Network

Improving health outcomes for Ohio’s most vulnerable populations is rarely as simple as identifying a problem and solving it with just one answer. A pregnant mom may need prenatal care, but she also may need reliable transportation to get to her appointments, childcare for her other kids, or nutritious food for herself and her family. An older adult managing a chronic condition may need more than a prescription. They may need help understanding their coverage, a ride to the pharmacy, or food that fits both their diet and their budget.

Solving health problems means solving for a lot of things that never show up on a chart, and that takes coordination among many different people and organizations working toward the same outcome.

Ohio has spent more than a decade building exactly that kind of coordination. Today, it’s a mature, evidence-based network for community care operating successfully in the majority of Ohio’s 88 counties. It’s a model that other states are now investing significant time and money to emulate.

Built From the Ground Up

Our network didn’t start with a grand plan. It started organically, in communities, with community health workers and the HUBs that support them.

A community health worker, often referred to as a CHW, is someone with a shared background or lived experience with the people they serve, often coming from the same community or a similar walk of life. That shared experience builds a level of trust that’s difficult to earn any other way. Community health workers sit outside the traditional medical system, but they help bridge the gap between it and the people who need it, educating, advocating and walking alongside someone as they navigate different systems of care.

A HUB, in turn, is the organizing structure around that work — the entity that connects community health workers across a community, coordinates their efforts, documents outcomes and brings partners together around a shared, evidence-based model of care.

In 2014, there were just three HUBs in Ohio. Over time, with growing support from health plans and other funders, that number grew. Today, HUBs operate in 79 of Ohio’s 88 counties, and the network — all built from the ground up, community by community — continues to expand.

Ohio’s statewide community care infrastructure began to take shape as more HUBs formed and informally supported each other. That growth accelerated during COVID-19. HUBs across the state began meeting regularly to solve shared problems, from how to safely support clients during the pandemic to practices for identifying the best partners in a given community. Those conversations grew into something bigger, as HUBs began sharing data, tips for reporting progress and outcomes, and best practices for building better partnerships with health plans and other organizations. Out of that came Partnerships for Advancing Community Health (PACH), formed so Ohio’s HUBs and community health workers could keep improving as a collective rather than working in isolation.

Partnership in Action

That collective effort is paying off. PACH’s network operates on a nationally recognized evidence-based model of community care coordination, Pathways Community HUB Institute^® Model, which is built to advance healthy outcomes. Working alongside Ohio’s Medicaid managed care plans and other partners, HUBs don’t just refer people to services. They document outcomes and, in many cases, are reimbursed only if specific outcomes are achieved.

Support for pregnant individuals is a clear example of how this works. Community health workers help pregnant women connect to prenatal care and work through whatever barriers stand in the way, whether that’s transportation, housing instability or something else entirely. The goal is straightforward: a healthy baby, born full term and at a healthy weight. When that outcome is achieved, the HUB is reimbursed for the work behind it. All of Ohio’s Medicaid managed care plans contract with HUBs to support pregnant women, a reflection of how deeply this model of accountable, outcomes-based care has taken root across the state.

Community health workers also help individuals with chronic health conditions navigate the healthcare system while addressing barriers such as food access or health insurance coverage. The outcomes for these individuals align with Ohio Medicaid managed care plan goals such as a completed annual well visit or maintaining Medicaid eligibility.

A Partnership Worth Investing In

None of this would be possible without partnerships. PACH and its HUBs bring together an often-fragmented set of funding sources and stakeholders, including Medicaid managed care plans, local health departments, philanthropic organizations and others, and do the hard work of aligning them around a single person’s needs. One well-meaning nonprofit could never do this alone. Building and sustaining a network like this one took, and continues to take, genuine partnership among health plans, community organizations and the state.

We are deeply grateful for those partnerships. Ohio’s Medicaid managed care plans have supported this work for almost two decades, recognizing that when a community health worker helps someone access care, resolve a barrier or stay healthy, everyone benefits: the individual, the community and the broader healthcare system. That kind of sustained collaboration, especially at a time when healthcare costs are a concern for everyone — plans, providers, taxpayers and patients alike — reflects a shared understanding that investing in community-based care is one of the most effective ways to improve health and reduce costs at the same time.

We look forward to building on these partnerships in the years ahead. Ohio has already built something other states are trying to replicate, but our work isn’t finished. There is more we can do together, such as expanding our capacity, reaching more Ohioans, and aligning even further with the priorities of MyCare and Medicaid managed care plans. We have a great deal to be proud of and even more to look forward to, together.