Success Story
Harris County HUB
In 2019, the Network of Behavioral Health Providers - Houston launched the C3 Pilot in the Houston, Texas area, focusing on zip codes shown to have the highest mental health needs. In the same year, a coalition of social, primary, and behavioral health organizations launched an initiative called Healthy Woman Houston (HWH), aimed at addressing maternal mortality and morbidity in the zip codes in Houston and the surrounding area with the highest mortality rates for women who had recently given birth.
The two pilots examined their impact over a two-year period using the Pathways model, and as a result of successful outcomes, contemplated how the work of the two projects could be continued and expanded. The groups launched the planning process to fully implement the Pathways Community HUB (PCH) model in the greater Houston area. With guidance from CCS Health™, a group of more than 30 health, behavioral health, social service organizations, and social service collaboratives—representing over 100 organizations—engaged in the work and developed the framework for what is now known as Harris County Pathways Community HUB (PCH). The intent of the PCH is to establish a more sustainable, community-centric solution to make maternal health and behavioral health services more accessible to eligible residents in Harris County.
- Continue and expand the work done through the C3 and Healthy Women Houston pilots
Leverage community resources in the service area
Track, measure and scale the services they’re already providing
Continue to identify significant need areas in their community
When Harris County PCH leadership reached out to CCS Health™, they were looking to leverage data, make them accessible and understandable to the layperson, and scale the success they had already achieved. We recommended CCS Health™ Fortify, which includes the Community Health Record, and allows them to capture all client information digitally using standard, out-of-the-box forms as well as enable them to quickly and easily refer clients to local services. They also needed to be able to scale their operations with a small team; the invoicing feature made it simple for them to bill multiple agencies at once.
Even in their first months of using the Community Health Record, they were able to leverage the digital snapshot of client information to identify trends in needed services. From there, they could prioritize partnerships with specific resource providers to ensure that clients had access to the support they needed. Noticing that several clients were experiencing housing crises, they connected with a housing collaborative to expand that relationship and improve their ability to address barriers to health.
Identified significant housing needs with support from the Community Health Record and established a referral partnership to close one housing Pathway within the first 60 days
With the support of CCS™, Harris County PCH was able to track the newly launched Learning Modules from PCHI®, and the successful completion of other Pathways, such as Substance Use and the Social Service Pathways
The invoicing feature improved the efficiency of the billing cycle
- Improved the engagement rate for referrals by reinforcing the process with community health workers and supervisors including educating staff on the importance of documentation in the CCS™ database for tracking and measuring
“From a supervisor’s standpoint, I want to know what’s open, what’s not, and what I can support. With the paper documents, there’s no way to give that kind of support. If you go to the system, it’s ordered. It’s structured. I can quickly see what’s going on with the client…. I can see what I need to see in a concise amount of time so I can then go out into the community and market the program and work with managed care organizations.”
– LaToya Shields, Supervisor, Harris County Pathways Community HUB