New Partnership to Reach At-Risk Families Kicks Off with Immunization Education

The Ohio Chapter, American Academy of Pediatrics (Ohio AAP) began a new, exciting partnership with the Pathways Community HUBs in Ohio earlier this year. This partnership will allow the Ohio AAP to take the education and information from the variety of programs it offers directly to those families who have the highest need in Ohio.

The “Pathways Model” was created by OH AAP member and pediatrician, Mark Redding, MD, FAAP, and his wife, Sarah Redding, MD, MPH, in 2001. The model evolved into the “Pathways Community HUB” model, which works to identify and address social and health-related risk factors, and collect data on the risk factor, the way it was addressed, and whether there was an improvement. The first Community HUB in Richland County was started in support of an Ohio AAP sponsored CATCH Grant.

“The Pathways Community HUB model was developed to provide infrastructure for community-based care coordination and to shift the focus to outcomes for individuals and families,” said Dr. Sarah Redding.

Ohio is home to six certified Pathway HUBs that work with dozens of organizations in their communities to identify clients that meet certain risk factors. Clients are identified by referral to the HUBs and then contacted by one of the HUB’s Community Health Workers (CHW). These CHWs are trained and certified through the Ohio Board of Nursing.  The HUBs receive national certification through the Rockville Institute in Maryland.

The CHW meets with the client, often at the client’s home, and conducts a comprehensive risk assessment. Each risk factor is translated into a “Pathway,” which is like an algorithm that leads the CHW through the steps necessary to identify and address the risk. Pathways are tracked to  measurable outcomes, and this comprehensive approach and heightened level of accountability leads to improved outcomes and reduced costs.

“Community health workers receive training and team based supervision to identify and address a comprehensive set of health social and behavioral health risk factors,” said Dr. Mark Redding. “The relationship that CHWs have with their clients is critical.  CHWs are at their best when they are from and part of the communities they serve.  They have the relationship skills to help address factors that hinge on behavior changes.  CHWs can help clients achieve cessation of tobacco and other substances, compliance with medical visits, adult education and employment for their clients.  Their ability to address these critical risk factors relate to the ongoing supportive relationships they develop.  Achieving positive outcomes requires a comprehensive team approach that addresses more than access to medical care.”

Conversations for a partnership between the HUBs and Ohio AAP began in 2016 with discussions on taking the Chapter’s existing programs with information that could be spread directly to families, and providing that education and training on these topics to the community health workers in the HUBs. The Chapter then secured four funding sources to engage the HUBs, and the first one rolled out was on the topic of immunizations in June 2017. The Chapter is finalizing the trainings from their Parenting at Mealtime and Playtime Program, Healthy Tomorrows/Injury Prevention Program, and Good4Growth Program, which will roll out over the next year.

“The Chapter is thrilled to be involved in this partnership with the HUBs,” said Mike Gittelman, MD, FAAP, the Ohio AAP’s Medical Director of the HUB Program. “We are working with both Mark and Sarah Redding to educate the CHWs and make sure they have more tools to help the families that they see every day.”

The six Pathways HUBs in Ohio cover several Ohio counties and that catchment area continues to grow as each HUB seeks additional funding to see more clients. Ohio’s pediatricians can easily refer patients to a HUB in their area by using the phone number below.

HUB: Care Coordination Network

  • Catchment Area: Franklin County
  • Client: Children 2-5 years of age, pregnant women
  • Contact: 614-227-2700

HUB: Community Health Access Project HUB

  • Catchment Area: Crawford, Ashland, Richland, Morrow, Knox, Huron Counties
  • Client: All ages
  • Contact: 419-774-4384

HUB: Health Care Access Now

  • Catchment Area: Hamilton County
  • Client: Pregnant women and Crohn’s disease patients
  • Contact: 513-707-5697

HUB: Mahoning Valley Pathways HUB

  • Catchment Area: Mahoning County
  • Client: Pregnant women
  • Contact: 330-270-2855

HUB: Northwest Ohio Pathways HUB

  • Catchment Area: Lucas, Wood, Fulton, Sandusky, Erie, Allen Counties
  • Client: Pregnant women, women with children up to age 2, adults with chronic diseases
  • Contact: 419-842-0800 

HUB: Summit County Pathways HUB

  • Catchment Area: Summit County
  • Client: Pregnant women
  • Contact: 330-376-7730

If you have questions about this partnership, program topics or referrals, contact Melissa Wervey Arnold, Ohio AAP CEO, at, or Mike Gittelman, MD, FAAP, Medical Lead for HUB Integration and Ohio AAP President-Elect, at

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