Community HUB Model
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:
- Identifying at-risk populations
- Developing tailored “pathways” programs to connect these individuals to needed services
- 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
Examples of Rural Community HUB Programs
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.
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.
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
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)
The Intersection of Rural
Poverty and Federal Human Services Programs
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
Organization(s): National Advisory Committee on Rural Health and Human Services