2018 - Reyneth

1. Pierce County ACH -
Pathways: Passage 2
Motherhood
10.31.18

2. KWA CHC Sea Mar HopeSparks
CARE
COORDINATION
AGENCIES
COMMUNITY
HUB
2
• Same program delivery across all care coordination agencies
• Distributed according to client choice then agency capacity
• Incorporates the role of the Community Health Worker
• 5 out of 15 of Community Health Workers are Spanish-speaking
Regional Organization and
Tracking of Care Coordination

3. 20 Core Pathways — National Certification
Adult Education
Employment
Health Insurance
Housing
Medical Home
Medical Referral
Medication Assessment
Medication Management
Smoking Cessation
Social Service Referral
*Source: Sarah Redding, MD January 26, 2017
Behavioral Referral
Developmental Screening
Developmental Referral
Education
Family Planning
Immunization Screening
Immunization Referral
Lead Screening
Pregnancy
Postpartum

4. The Pathways under the Pathways
FAMILY PLANNING
 Tubal Ligation
 Vasectomy
 IUD
 Implant
 Shot
 Abstinence
 Natural Family Planning
 Pills
 Patch
 Ring
 Diaphragm
 Condom
 Cervical Cap
 Spermicide
 Other
Source: Sarah Redding, MD January 26, 2017
MEDICAL REFERRAL
 Primary Care
 Specialty Medical Care
 Dental
 Vision
 Hearing
 Family Planning
 Mental Health
 Substance abuse
 Speech and Language
 Pharmacy
 Other, please specify in record
SOCIAL SERVICE REFERRAL
 Child Assistance
 Family Assistance
 Food Assistance / WIC
 Housing Assistance
 Insurance Assistance
 Financial Assistance
 Medication Assistance
 Transportation Assistance
 Job/Employment Assistance
 Education Assistance
 Medical Debt Assistance
 Legal Assistance
 Parent Education Assistance
 Domestic Violence Assistance
 Clothing Assistance
 Utilities Assistance
 Translation Assistance
 Help Me Grow

5. Incoming referrals
Receive referrals
Text line 253-353-7250
Referral Partners
Maternity Support Services
Health Department
Anyone on behalf of client (w/ client consent)
Community HUB
Looks at Residence
Pregnant
1 of 3 Risk Factors
Insurance
Assigns to Care Coordination Agency
Care Coordination Agency
Assign Community Health Worker
Contact client within 2 business days

7. Infant Mortality Rates
IN PIERCE COUNTY:
4.7
INFANT DEATHS PER 1,000
LIVE BIRTHS
(higher than state average)
INFANT MORTALITY RATES VARY
SIGNIFICANTLY BY RACE/ETHNICITY
12%
8%
13%
18%
20%
29%
White
Asian
African American
Am Indian / Alaska Native
THE INFANT MORTALITY RATE IN AFRICAN-AMERICAN
AND AMERICAN-INDIAN POPULATIONS IS TWICE THAT
OF THE WHITE POPULATION
Per 1,000 live births

8. TO QUALIFY:
• Residing in Pierce County
• Medicaid or Medicaid Eligible
• High Risk Factors
• Previous poor birth outcome
• Tobacco or Substance Use
• Mental Health Concerns

9. Progress Report
Source: Sarah Redding, MD January 26, 2017
Pathways
All Pregnant Women Latina Pregnancy
Medical Social Service Medical Social Service
Dental Clothing/Baby Items Dental WIC
Specialty Medicine WIC Specialty Medicine Clothing/Baby Items
Primary Care Food Assistance Primary Care Food Assistance
Mental Health Housing Assistance Mental Health Translation Assistance
Maternity Support
Services
Transportation Maternity Support
Services
Transportation
AVG # OF PATHWAYS
PER CLIENT5 AVG # OF PATHWAYS
PER LATINA CLIENT6

10. How you can get involved
 Refer potential clients – client consent
 Inform clients, encourage them to call or text
 Become a referral partner – easy access

12. Reyneth Reyes Morales
Program Hub Manager
Pierce County ACH
reyneth@piercecountyach.org