Hopewell Health Centers 

The Georgia Health Policy Center recently spoke to Richard Wittberg, the network director for Hopewell Health Centers, about how the Federally Qualified Health Center is at the center of efforts to develop a network that uses community health workers (CHWs) for care coordination in southeastern Ohio. 


To date, what has been the biggest accomplishment or win in your program?  

The network development grant allowed us to convene the state health plans and get them engaged in tracking health statistics. One of the first things that I am very proud of is that one of the plans invested $15,000 to help hire a CHW. We are working collaboratively with the plan to identify their high-risk members, as well as those we identify clinically as high-risk. It is very exciting that we have a collaborative project between Hopewell and the plans and that we are actively trying to put a number on what this service saves. Once we do that, then, it is going to be very easy for us to replicate it, providing that the numbers show that it is worth replicating. 

Our average A1C reduction has been over two points and that is pretty dramatic. People make assumptions that patients are choosing not to be compliant. But there are things that get in the way of them doing what the doctor wants. They are overwhelmed. They cannot understand all the information in those 10 minutes with the doctor. But, by having a CHW going into their home, seeing what the barriers are, and finding ways to help them overcome those barriers, we see better outcomes. It may not be as much health coaching as it is finding ways to help them with utility bills or getting the food that they need. 

The second thing I am proud of is setting up a Pathways Community HUB in southeastern Ohio. This model uses CHWs to complete pathways with patients and then the hub that hires them can bill for that, which helps build sustainably for CHWs. It is only because of the network development grant that we got that up and running. This has really generated interest from local health departments that want to get involved, as it can help with their revenue and accreditation, too. 


What is a tip or early learning that you would share with an organization launching a similar network?  

When hiring, I have always talked about the three Ps — passion, patience, persistence. The same can be said for a network. Nothing happens overnight. You need great ideas, but also the time to build relationships. The other tip is to use data. Health plans are data-driven. You have to get the right data that can convince them of something. Data on health improvement will get you a pat on the back, but it is not likely to result in money. You have to be able to demonstrate that there are cost savings. It is almost like we, as health care providers, have to learn a different language. That is not a bad thing because you cannot sustain this kind of a program just based on passion for health care improvement. You have to be able to get the plans to see that this benefits their bottom line, too. 


How do you see participation in the Federal Office of Rural Health Policy’s Network Development Grant Program impacting your broader health improvement efforts?  

If not for the network development grant, we would not have been able to convene the groups that we have. Pathways would not have gotten started. You cannot do these things on your own. You have to have partners and to keep the partnerships growing.  

When you start something, like the Pathways Community HUB, and it has early success, it grows in ways you may not have been expecting. You have to be open to those opportunities as they crop up. Our focus initially was the high-risk population. But now, we are going in other ways, too. We are starting a pilot on falls, which are very expensive, where we can get in the home and make home modifications. Childhood asthma is another expensive condition where outcomes and cost can be addressed with a CHW in the home. So, I am just enjoying this ride and jumping on opportunities as they come up because of our growing network. 


What will your organization be doing more of or differently to emerge stronger from the pandemic? 

Because we could not put as much attention and focus on the home visiting, it allowed us to build infrastructure around Pathways and it allowed us to focus more on relationships. I think things happen for a reason. If you cannot go in the direction that you want to go, that probably means there’s another direction that you need to go. Keep your ears open, your eyes open, and your mind open. 

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