Pathways Model Aligns Care, Population Health.

Pathways assigned Grace a community health worker who for eight months visited her at home and brought her supplies before Grace had the courage to leave her house and re-enter the world. Grace resumed services from community mental health and began treatment for her diabetes. After 18 months of support from her community health worker and regular counseling, Grace’s diabetes is now under control and she is ready to manage it on her own. Without Pathways, Grace likely would still be confined to her house with her health deteriorating. This is just one of many stories about people who are chronically ill and who could be better served by their health systems. Most are lowincome, uninsured or on some form of public assistance. Most experience several barriers to a healthy life; many have mental health issues and are socially and emotionally isolated. Grace’s story illustrates the street-level challenges of transforming health care from a volumebased to a value-based system that seeks to make people healthy and keep them out of emergency rooms and hospital beds. Mercy Health Muskegon uses the Pathways approach to align its community benefit ministry with the realities of health care transformation — particularly in terms of integrating clinical and community care and transitioning to population health management.