Highmark Wholecare, formerly Gateway Health, a leading managed care organization dedicated to caring for the total health of its members, and the 1889 Jefferson Center for Population Health (1889 JCPH) have partnered to improve diabetes health outcomes and reduce health disparities for Highmark Wholecare members living in Cambria and Somerset Counties.

The Community Care HUB, implemented by the 1889 Jefferson Center for Population Health, offers community-based care coordination for a variety of at-risk individuals. The Community Care HUB follows the Pathways Community HUB model developed by the Pathways Community HUB Institute. The HUB model addresses and mitigates risk factors associated with poor health outcomes.

Highmark Wholecare members eligible for this free service are connected with a community health worker who identifies and addresses their health needs. Through face-to-face interactions, the community health worker strives to improve health outcomes by linking eligible members to various community resources that reduce both medical and social barriers to care, such as employment, housing, food access, and transportation needs. 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. Community health workers may also provide basic diabetes education to empower members to take control of their health.

“We are proud to partner with the Community Care HUB, an organization that shares our whole person care approach,” said Nicole Kohler, Clinical Design Specialist, Highmark Wholecare. “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.”

According to the Centers for Disease Control and Prevention (CDC), more than 37 million people in the United States have diabetes, and one in five of them are unaware. Diabetes can lead to other health problems like heart disease, kidney disease, and nerve damage.

“Collaborative partnerships like the one we’re embarking on with Highmark Wholecare are essential to improving the health and wellbeing people in the communities we serve,” said Billy Oglesby, Dean, Jefferson College of Population Health. “We’re looking forward to learning from one another and sharing that knowledge with others.”

In 2022, County Health Rankings* showed Cambria County ranked 62 out of the 67 counties in Pennsylvania for health outcomes and Somerset County ranked 43. Both counties ranked among the least healthy when it came to health factors impacting the communities.

“We are grateful to collaborate with Highmark Wholecare and connect community health workers (CHWs) with their at-risk diabetic members,” said Jeannine McMillan, Executive Director, 1889 Jefferson Center for Population Health/Community Care HUB. “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.”

Through its leading Medicaid and Medicare programs, Highmark Wholecare is coordinating health care that goes beyond doctors and medicine to deliver whole person care to the communities it serves. Highmark Wholecare’s legacy of addressing social determinants of health (SDoH), which refers to the conditions in which people are born, grow, live, work, and age, can be traced back to the start of the company 30 years ago.

To learn more about the Community Care HUB, visit www.1889jeffersoncenter.org/hub.


* countyhealthrankings.org



About Highmark Wholecare

We believe in caring for the whole person in all communities where the need is greatest. We see a future in which everyone has equal opportunity to achieve their best health. Through our leading Medicaid and Medicare programs, we are coordinating health care that goes beyond doctors and medicine that helps members achieve not just physical health, but also delivers whole person care. Our team members are helping to drive this new kind of health care for our 410,000 Medicaid and Medicare members in collaboration with a network of 29,000 primary care physicians, specialists, hospitals, and other ancillary providers. We are also committed to supporting our neighbors through our many community outreach and engagement programs.

About 1889 Jefferson Center for Population Health

The 1889 Jefferson Center for Population Health was founded as a collaborative research and resource center focused on population health and disease prevention to benefit the citizens

living in Cambria and Somerset Counties. The Center’s work focuses on identifying key contributing factors to poor health in the region and developing proactive and responsive strategies to address them. The Center is the first of its kind established in a small rural

community rather than a large metropolitan area. It is envisioned that the work of the Center will provide a national model of how population health interventions can work in rural communities.