Info For Patient Referrals

Long known for helping disadvantaged pregnant women in Lucas County deliver healthy babies, the Northwest Ohio Pathways HUB has expanded to coordinate evidence-based care for adults and to reduce the burden of chronic disease.

One of the main areas of focus is helping adults who live in low-income Toledo neighborhoods manage or prevent chronic diseases. The program is especially focused on assisting residents with or at risk for prediabetes, diabetes and heart disease. Community health workers coordinated by the Northwest Ohio Pathways HUB help residents get access to needed medical care and social services, including food, housing, transportation and clothing.

Community health workers find and enroll residents with barriers that have prevented them from getting medical care for chronic diseases or who are at risk for them. Potential barriers include lack of insurance coverage or transportation to get to medical appointments. Besides helping to remove various barriers to care — and to find needed social services — community health workers will connect Pathways clients to prevention and medical services. Diabetes education, smoking cessation and exercise programs are examples.

Eligible clients who are uninsured will be enrolled in Medicaid or Toledo/Lucas County CareNet. All clients will be connected to a medical home for primary medical care within 30 days of program enrollment. Community health workers will work with enrolled clients to educate them about healthy lifestyles and to track exercise, eating habits and biometric test results, such as blood pressure.

Patient Referrals

The Northwest Ohio Pathways HUB is seeking referrals of patients with or at risk for prediabetes, diabetes and heart disease. To make a referral, please click here for the form.

Here are the referral guidelines.

LOW INCOME:
• Defined as Medicaid eligible or uninsured with income up to 200% of the federal poverty level.

TWO OR MORE RISK FACTORS FOR DIABETES AND/OR HEART DISEASE:
• Age 35-65
• Race (African Americans, Hispanics, American Indians & Asians are at a higher risk)
• Obesity
• Adult Smoker or Adult Tobacco Use
• Family History
• Physical Inactivity
• Stress
• Abnormal Cholesterol & Triglyceride levels
• Alcohol Abuse
• Poor Diet
• Residing in a ZIP code with a history of having a high percentage of risk or diagnoses of chronic disease (43604, 43605, 43607, 43608, 43609, 43620)

TWO OR MORE SOCIAL FACTORS:
• Food Assistance/WIC/SNAP
• Housing Assistance
• Insurance Assistance
• Financial Assistance
• Medication AssistancePixabay mother and daughter
• Transportation Assistance
• Job/Employment Assistance
• Education Assistance
• Medical Debt Assistance
• Legal Assistance
• Parent Education Assistance
• Domestic Violence Assistance
• Clothing Assistance
• Utilities Assistance
• Translation Assistance

For more information, please contact:

Alishea Sutton
Evaluation Specialist
asutton@hcno.org
419-842-0800

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