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Community HUB Model

The Community Health Access Project developed the Community HUB Model to connect at-risk individuals to health and social services and improve their health outcomes. The Community HUB serves as a central registry of at-risk individuals for a network of care coordination agencies, helping to eliminate organizational silos and reduce the duplication of services. These care coordination agencies could include hospitals, community-based organizations, and social service departments, among many others.

The Community HUB model involves:

  1. Identifying at-risk populations
  2. Developing tailored “pathways” programs to connect these individuals to needed services
  3. Documenting outcomes

Pathways are designed to address key health or social issues affecting at risk-populations and are associated with measureable outcomes. For example, a Pregnancy Pathway can involve securing prenatal care for pregnant women in order to decrease the incidence of infant mortality. Pathways are the primary mechanism through which the Community HUB tracks the utilization of services by at-risk individuals and ties financial incentives to outcomes.

This model relies on care coordinators to engage at-risk individuals, register them with the Community HUB, identify barriers to needed health and social services, ensure they complete the necessary pathways, and document their progress on a regular basis.

Examples of Rural Community HUB Programs

  • Integrating Professionals for Appalachian Children (IPAC) serves as a Community HUB for a network of partners in rural Southeast Ohio. IPAC has established Pregnancy Pathway for high-risk pregnant women and is also piloting Pathways programs for children who frequently use the emergency department for non-urgent care and children with histories of trauma and/or foster care placements.
  • Rural and Urban Access to Health: This network of field-based workers in central Indiana connects vulnerable populations, particularly migrant workers and immigrants, to various health and human services.
  • Access El Dorado (ACCEL): ACCEL has created eight interagency pathways using community health workers to help families with low incomes access care for children age 18 and younger. The eight care pathways are: newborn health insurance, health insurance for children, health insurance retention, medical home, newborn utilization of medical home, pediatric mental health consult, orthopedic consult, and pain management telemedicine consult.
  • CHOICE Regional Health Network (CHOICE): CHOICE uses health resources coordinators to help vulnerable populations obtain insurance coverage and to access healthcare services. CHOICE also acts as the administrative hub for interventions for clients with a history of frequent emergency department visits.
  • Northeast Oregon Network (NEON): NEON is a collaborative comprised of rural health providers, agencies, and community members from three counties in northeastern Oregon. The mission of the collaborative is to increase access to integrated healthcare through identifying system gaps, facilitating community developed solutions, and advocating for policy changes.

The Agency for Healthcare Research and Quality (AHRQ) offers several helpful tools for communities seeking to implement a Community HUB and accompanying pathways. These following guides include valuable resources to facilitate the implementation process, including sample case management plans, checklists, reports, and referral, intake, and discharge forms.

Considerations for Implementation

It can be time-intensive to create an infrastructure for services integration across multiple agencies. Leadership must allow for flexibility within the multi-agency network in order to address issues. Cross-jurisdictional issues may arise around the ownership, costs, and staffing of multi-agency hubs attempting to provide a range of health and human services. All participating agencies should agree on common goals and meet regularly as a team. The hub will need to determine what mechanisms should be used to measure the effectiveness of the programs and ensure that these measurements are relevant to the participating agencies. Leadership should also define clear lines of communication and accountability for the multi-agency hub.

Resources to Learn More

AHRQ Research Activities Newsletter
Document
This newsletter contains an article called “Community hubs ensure better care for the most vulnerable,” which provides an overview of the Community Pathways HUB model implemented in Ohio.
Organization(s): Agency for Healthcare Research and Quality (AHRQ)
Date: 6/2011

The Intersection of Rural Poverty and Federal Human Services Programs
Document
This policy brief studies the relationship between federal human services programs and rural poverty. It includes two case studies that are similar, but use different types of anchor organizations to coordinate rural services.
Organization(s): National Advisory Committee on Rural Health and Human Services
Date: 1/2014