Community-Based Care Coordination (Pathways Community HUB)
The Pathways Community HUB model uses a comprehensive risk identification and reduction mechanism in combination with a centralized infrastructure to coordinate care across a network of agencies serving at-risk clients. This allows communities to use resources more efficiently and effectively to address risk and improve health outcomes. The Pathways Community HUB does not replace, but rather supplements and supports, existing case managers, nurses, social workers, community health workers, care coordinators, etc. partnering with multi-sector community stakeholders.
At the foundation of the model the primary components of the Pathways Community HUB are:
1. Core Pathways: measurement tools to define the problem to be addressed (health or social issue), the desired measureable outcome, and the key intervention steps to achieve the outcome.
2. Community HUB: a regional point of registry and outcome tracking that networks together health care providers, social service agencies, and health care payers that implement these Pathways.
3. Pathway Payments: care coordination payments based on outcomes instead of activities.
At the foundation of the model the primary components of the Pathways Community HUB are:
1. Core Pathways: measurement tools to define the problem to be addressed (health or social issue), the desired measureable outcome, and the key intervention steps to achieve the outcome.
2. Community HUB: a regional point of registry and outcome tracking that networks together health care providers, social service agencies, and health care payers that implement these Pathways.
3. Pathway Payments: care coordination payments based on outcomes instead of activities.
Workgroup Resources
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02-13-2019 HUB Advisory Board Meeting
| february_2019_hub_advisory_board_meeting_agenda.pdf |
| due_diligence_p_p_draft.pdf |
| advisory_board_meeting_summary_february_2019_final.pdf |
01-09-2019 HUB Advisory Board Meeting
| january_hub_advisory_board_meeting_agenda_final_draft.pdf |
| ahp-hub_process_improvements_01-2019.pdf |
| advisory_board_meeting_summary_january_2019_final.pdf |
| rolling_social_service_scorecard-q4_2018.pdf |
| rolling_pathways_risk_scorecard-ytd_2018.pdf |
| rolling_med_ref_scorecard_ytd-2018.pdf |
| hub_contact_list.pdf |
12-17-2018 HUB Advisory Board Meeting
| hub_advisory_board_meeting_agenda_12-17-2018.pdf |
| advisory_board_meeting_summary_12-17-2018.pdf |
| ahp-ph-pdsa-01__quality_improvement-improving_contact_with_referred_clients_km_12-17-2018.pdf |
08-09-18 HUB Advisory Board Meeting
| hub_advisory_board_meeting_agenda_08-09-2018.pdf |
| hub_advisory_board_minutes_8-9-18.pdf |
07.12.18 HUB Advisory Board Meeting
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06.28.18 HUB Advisory Board Meeting
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| 06.28.18 HUB Advisory Board Meeting Materials |
06.27.18 Workgroup Meeting
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| 06.27.18 HUB Workgroup Meeting Materials |
05.23.18 Workgroup Meeting
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| 05.23.18 HUB Workgroup Meting Materials |
04.25.18 Workgroup Meeting
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03.28.18 Workgroup Meeting
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| 03.28.18 HUB Workgroup Meeting Materials |
02.23.18 Workgroup Meeting
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