1889 Jefferson Center, Highmark join to connect residents, health workers

Randy Griffith, The Tribune-Democrat, Johnstown, Pa.
·3 min read

Jan. 18—JOHNSTOWN, Pa. — A local organization of "problem-solvers" is joining forces with a leading health insurance company to help at-risk people improve diabetes health outcomes and reduce disparities.

Highmark's Wholecare program has partnered with Johnstown-based 1889 Jefferson Center for Population Health to connect Wholecare members with the foundation's Community Care HUB.

Implemented in 2018, the Community Care HUB is a coalition of local agencies that employ community health workers to connect one-on-one with Cambria and Somerset county residents facing barriers to healthy living.

Through the partnership, members of Highmark's Wholecare Medicare/Medicaid plans will be connected with the HUB's community health workers, who identify and address their health needs.

"We are proud to partner with the Community Care HUB, an organization that shares our whole-person care approach," said Nicole Kohler, a clinical design specialist with Highmark. "This partnership highlights our belief that more frequent positive health outcomes are achieved when we meet members where they live, work and play. We have seen success with this model specific to maternal health, and are confident that same success for members living with diabetes will be realized."

Helen Robinson is the community health worker supervisor for HUB participant Community Action Partnership of Cambria County. She explained that the health workers connect with clients at least once a month as part of the free program. The workers ask questions about the clients' health to identify "problems" they have in healthy living.

Following the Pathways Community HUB model developed by the Pathways Community HUB Institute, the local health workers identify the barriers and look for solutions through 21 "pathways."

Among the pathways, or barriers to health, are employment, housing, food access, transportation and access to primary care. Clients are then connected with agencies and programs that address those individual needs.

"We are able to stabilize them through the crisis," Robinson said. "Support between the agencies in the program has been phenomenal. If (the agencies) need something, they can reach out to me. If I need something, I can reach out to them."

As part of the diabetes care team, community health workers connect Highmark Wholecare members to diabetes services within the community to provide overdue medical care when appropriate, such as routine A1C testing and foot and eye exams.

"Collaborative partnerships like the one we're embarking on with Highmark Wholecare are essential to improving the health and well-being of people in the communities we serve," said Billy Oglesby, dean of the Jefferson College of Population Health at Thomas Jefferson University. "We're looking forward to learning from one another and sharing that knowledge with others."

According to the Centers for Disease Control and Prevention, more than 37 million people in the United States have diabetes, and one in five of them is unaware of it.

"We are grateful to collaborate with Highmark Wholecare and connect community health workers with their at-risk diabetic members," 1889 Jefferson Center Executive Director Jeannine McMillan said. "The care coordination that the CHWs provide can have a significant positive impact on improving the health outcomes of those most vulnerable in our communities."