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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.

Workgroup Resources

Pathways Community HUB Workgroup Charter
File Size: 170 kb
File Type: pdf
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Pathways Community HUB Workgroup Member Agreement
File Size: 120 kb
File Type: pdf
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Request for Proposals Pathways Community HUB
File Size: 1680 kb
File Type: pdf
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Pathways Community HUB Manual
Pathways Community HUB Quick Start Guide
HUB Model Standareds and Prerequisites

12​-11-2019 ​HUB Advisory Board Meeting

draft-hub_advisory_board_agenda_12_11_2019.pdf
File Size: 149 kb
File Type: pdf
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uwcophp_final_presentation_community_development_ahp_and_cis_december_2019.pdf
File Size: 1328 kb
File Type: pdf
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cc-ahp_pw_hub_september_2019_monthly_deliverable_report.pdf
File Size: 1667 kb
File Type: pdf
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November 2019 ​HUB Advisory Board Online Updates

11.01.19_pathways_hub_report_final.pdf
File Size: 813 kb
File Type: pdf
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cc-ahp_pw_hub_september_2019_monthly_deliverable_report.pdf
File Size: 1667 kb
File Type: pdf
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draft_september_2019_hub_advisory_board__meeting_minutes.pdf
File Size: 160 kb
File Type: pdf
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09-11-2019 ​HUB Advisory Board Meeting

hub_advisory_board_agenda_09_11_2019.pdf
File Size: 142 kb
File Type: pdf
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08_14_2019_hub_advisory_board_meeting_minutes.pdf
File Size: 182 kb
File Type: pdf
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ahp-hub_july_2019_monthly_deliverable_report.pdf
File Size: 535 kb
File Type: pdf
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ahp_hub_ab_cc_definition_08-14-2019.pdf
File Size: 67 kb
File Type: pdf
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​08-14-2019 ​HUB Advisory Board Meeting

hub_advisory_board_agenda_08_14_2019.pdf
File Size: 142 kb
File Type: pdf
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07_10_2019_hub_advisory_board_meeting_minutes_.pdf
File Size: 184 kb
File Type: pdf
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hub_project_workgroup_monthly_update_june_2019.pdf
File Size: 365 kb
File Type: pdf
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07-10-2019 ​HUB Advisory Board Meeting

07_10_2019_hub_advisory_board_meeting_minutes_.pdf
File Size: 184 kb
File Type: pdf
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cc-ahp_hub_presentation-07-10-2019.pdf
File Size: 1205 kb
File Type: pdf
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05_08_2019_may_hub_advisory_board_meeting_minutes_klm.pdf
File Size: 162 kb
File Type: pdf
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july_10_hub_advisory_board_meeting_agenda.pdf
File Size: 151 kb
File Type: pdf
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05-08-2019 ​HUB Advisory Board Meeting

may_2019_hub_advisory_board_agenda.pdf
File Size: 149 kb
File Type: pdf
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04_10_2019_april_hub_advisory_board_meeting_minutes.pdf
File Size: 173 kb
File Type: pdf
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april_2019_pathways_hub_advisory_board_data__1_.pdf
File Size: 245 kb
File Type: pdf
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04-10-2019 ​HUB Advisory Board Meeting

04_10_2019_april_hub_advisory_board_agenda.pdf
File Size: 156 kb
File Type: pdf
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03_13_2019_hub_advisory_board_meeting_minutes.pdf
File Size: 202 kb
File Type: pdf
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april_2019_pathways_hub_advisory_board_data.pdf
File Size: 237 kb
File Type: pdf
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chelan-douglas_county_resources_from_ccs_04-03-2019.pdf
File Size: 248 kb
File Type: pdf
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grant_county_resources_from_ccs_04-03-2019.pdf
File Size: 230 kb
File Type: pdf
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okanogan_county_resources_from_ccs_04-03-2019.pdf
File Size: 178 kb
File Type: pdf
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03-13-2019 ​HUB Advisory Board Meeting

hub_advisory_board_agenda_2019.3.13__1_.pdf
File Size: 194 kb
File Type: pdf
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february_2019_hub_advisory_board_meeting_notes.pdf
File Size: 160 kb
File Type: pdf
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march_2019_pathways_hub_advisory_board_data.pdf
File Size: 163 kb
File Type: pdf
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rolling_pathways_risk_scorecard-march_2019.pdf
File Size: 61 kb
File Type: pdf
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social_service_pathway-detail.pdf
File Size: 64 kb
File Type: pdf
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medical_referral_pathway_detail-oct_2018-feb_2019.pdf
File Size: 63 kb
File Type: pdf
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education_pathway_detail-oct_2018-feb_2019.pdf
File Size: 61 kb
File Type: pdf
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top_5_pathways_initiated.pdf
File Size: 162 kb
File Type: pdf
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hub_zone_map.pdf
File Size: 143 kb
File Type: pdf
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ahp_hub_zones.pdf
File Size: 132 kb
File Type: pdf
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client_letters_-_final_2_28_19.pdf
File Size: 138 kb
File Type: pdf
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brochure_v5_all_03-2019.pdf
File Size: 127 kb
File Type: pdf
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02-13-2019 ​HUB Advisory Board Meeting

february_2019_hub_advisory_board_meeting_agenda.pdf
File Size: 152 kb
File Type: pdf
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due_diligence_p_p_draft.pdf
File Size: 130 kb
File Type: pdf
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advisory_board_meeting_summary_february_2019_final.pdf
File Size: 336 kb
File Type: pdf
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january_2019_hub_advisory_board_meeting_notes.pdf
File Size: 191 kb
File Type: pdf
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01-09-2019 ​HUB Advisory Board Meeting

january_hub_advisory_board_meeting_agenda_final_draft.pdf
File Size: 511 kb
File Type: pdf
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ahp-hub_process_improvements_01-2019.pdf
File Size: 424 kb
File Type: pdf
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advisory_board_meeting_summary_january_2019_final.pdf
File Size: 565 kb
File Type: pdf
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rolling_social_service_scorecard-q4_2018.pdf
File Size: 415 kb
File Type: pdf
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rolling_pathways_risk_scorecard-ytd_2018.pdf
File Size: 529 kb
File Type: pdf
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rolling_med_ref_scorecard_ytd-2018.pdf
File Size: 403 kb
File Type: pdf
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hub_contact_list.pdf
File Size: 254 kb
File Type: pdf
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12-17-2018 ​HUB Advisory Board Meeting

hub_advisory_board_meeting_agenda_12-17-2018.pdf
File Size: 449 kb
File Type: pdf
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advisory_board_meeting_summary_12-17-2018.pdf
File Size: 477 kb
File Type: pdf
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ahp-ph-pdsa-01__quality_improvement-improving_contact_with_referred_clients_km_12-17-2018.pdf
File Size: 491 kb
File Type: pdf
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08-09-18 ​HUB Advisory Board Meeting

hub_advisory_board_meeting_agenda_08-09-2018.pdf
File Size: 450 kb
File Type: pdf
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hub_advisory_board_minutes_8-9-18.pdf
File Size: 684 kb
File Type: pdf
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07.12.18 HUB Advisory Board Meeting

07.12.18 HUB Advisory Board Agenda
File Size: 449 kb
File Type: pdf
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07.12.18 HUB Advisory Board Minutes
File Size: 632 kb
File Type: pdf
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06.28.18 HUB Advisory Board Meeting

06.28.18 HUB Advisory Board Agenda
File Size: 170 kb
File Type: pdf
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06.28.18 HUB Advisory Board Minutes
File Size: 119 kb
File Type: pdf
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06.28.18 HUB Advisory Board Meeting Materials
File Size: 904 kb
File Type: pdf
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06.27.18 Workgroup Meeting

06.27.18 HUB Workgroup Agenda
File Size: 193 kb
File Type: pdf
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06.27.18 HUB Workgroup Minutes
File Size: 244 kb
File Type: pdf
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06.27.18 HUB Workgroup Meeting Materials
File Size: 1092 kb
File Type: pdf
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05.23.18 Workgroup Meeting

05.23.18 HUB Workgroup Agenda
File Size: 172 kb
File Type: pdf
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05.23.18 HUB Workgroup Minutes
File Size: 222 kb
File Type: pdf
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05.23.18 HUB Workgroup Meting Materials
File Size: 765 kb
File Type: pdf
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04.25.18 Workgroup Meeting

04.25.18 HUB Workgroup Agenda
File Size: 170 kb
File Type: pdf
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04.25.18 HUB Workgroup Minutes
File Size: 178 kb
File Type: pdf
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04.25.18 HUB Workgroup Meeting Materials
File Size: 3888 kb
File Type: pdf
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Ranking Populations Results
File Size: 85 kb
File Type: pdf
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03.28.18 Workgroup Meeting

03.28.18 HUB Workgroup Agenda
File Size: 176 kb
File Type: pdf
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03.28.18 HUB Workgroup Minutes
File Size: 153 kb
File Type: pdf
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03.28.18 HUB Workgroup Meeting Materials
File Size: 1122 kb
File Type: pdf
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02.23.18 Workgroup Meeting

02.23.18 HUB Workgroup Agenda
File Size: 179 kb
File Type: pdf
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02.23.18 HUB Workgroup Meeting Materials
File Size: 2819 kb
File Type: pdf
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02.23.18 Medicaid Transformation Resources
File Size: 2954 kb
File Type: pdf
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02.23.18 HUB Workgroup Minutes
File Size: 174 kb
File Type: pdf
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