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Brooklyn Perinatal Network (BPN), along with the Leadership Team of the Brooklyn Coalition for Health Equity for Women and Families, is proposing a pilot to design, plan and implement the evidence-based, nationally tested Pathways HUB (P-HUB) approach in Central Brooklyn, NYC. The project will address maternal and child health in a hot spot for severe maternal morbidity.

The evidence-based Pathways Community Hub model will be collaboratively adapted by key stakeholders in order to complement existing systems and care delivery models without duplicating existing services. The model consists of two components: the Community HUB and the Pathways.

The Community HUB is a small, sustainable, lean administrative entity that oversees quality reporting, invoicing, and coordinating with each of the separate agencies. Hubs serve as a center for multiple CBOs who hire, train supervise and support the community health workers in order to:

1. Develop and maintain the contracts with care coordination funders.
2. Track quality and monitor performance.
3. Serve as a central resource for training, technology support, and community networking.

Working through the HUB infrastructure, the CBOs avoid service duplication to at risk clients, operate under a pay for performance model, and evolve into a progressively improving team able to meet programming and documentation requirements and conduct continuous quality improvement.

The Pathways refer to the standardized approach taken to assessing and addressing the myriad areas of health, social, and behavioral health risk experienced by those who are most vulnerable and at risk for poor outcomes.

The pilot will allow providers to effectively engage highly skilled community-based organizations able to target the needs of women who are at high risk for poor outcomes prior to conception and during the pregnancy, postpartum, and inter-conception periods. Community health workers from the participating network will be financed under the model’s pay for performance arrangement to link women to appropriate ongoing services and supports, including health home care management, primary care, behavioral health services, preventive services, and disease management. Every maternal and infant client will receive a comprehensive assessment of health social and behavioral health risk. Each identified modifiable factor of risk identified will be assigned a specific Pathway to measure the success of the CHW and care coordination team in connecting the individual to specific evidence-based interventions to address the risk factors. The approach will improve connections to needed clinical care and address the social determinants of health to improve maternal health and birth outcomes, prevent infant and maternal mortality and morbidity, and reduce ED utilization and hospital readmission rates.