Community-Based Care Coordination in Cambria & Somerset Counties
In September 2020, the Center for Population Health launched the Community Care HUB (HUB) for Cambria and Somerset counties. Developed by the Pathways Community HUB Institute, the HUB model aims to impact health outcomes by addressing risk factors associated with poor health outcomes. A HUB is an organized, outcome focused, network of Care Coordination Agencies (CCAs) who hire and train community health workers (CHWs) and connect at-risk individuals to needed services. The HUB’s CCAs are Alleghenies United Cerebral Palsy Service Coordination, Beginnings, Inc., and The Women’s Help Center.
The community health workers meet with participants face-to-face, preferably in their homes, then guide them through one or more of 21 Pathways designed to address their needs. The HUB model involves the collaboration of all community resources to reduce both medical and social barriers to care, like employment, housing and transportation, for individuals with complex health needs.
Core Features of the HUB
Pathways
The most common barriers to health outcomes, such as employment, housing, and transportation, are categorized into 21 standardized pathways.
Community Health Workers
Community Health Workers (CHWs) partner with HUB participants to complete pathways. CHWs are employed by Care Coordination Agencies.
Care Coordination Agencies
Social service agencies, health clinics, and community-based organizations partner with the HUB to employ Community Health Workers.
Outcome-based Model
Payers and funders contract with the HUB to pay for the completion of pathways for HUB participants. Outcome-based contracts are directly linked with better health outcomes of HUB participants.
Community Care HUB Advisory Committee
- Bruce Duke, MD
- Christy Berzonski, CCHW, Alleghenies United Cerebral Palsy
- Stephanie Buck, CHW, Beginnings, Inc.
- Yvette M. Madison, MSW, Professor of Social Work, Pennsylvania Highlands Community College
- April Carey, CHW, The Women’s Help Center
- Barbara Duryea, RN, Canary Health
- Gwen Msolomba, former CHW Supervisor/PhD candidate
- Tammy Rhoades, CEO, Alleghenies United Cerebral Palsy
- Jes Phillippi, Executive Director, Beginnings, Inc
- Tracy Shultz, Director of Operations, Magellan Behavioral Health in Cambria County
- Roxann Tyger, Executive Director, The Women’s Help Center
The HUB is PCHI certified from November 2024 through November 2027.
The Community Care HUB (HUB) received its full Certification from the Pathways Community HUB Institute® (PCHI®). Achieving full certification signifies the Community Care HUB meets the stringent national standards for quality community care coordination services. Receiving a three-year term of recertification means the HUB has undergone a rigorous peer-reviewed process and has demonstrated unwavering commitment to providing measurable, accountable, and high-quality programs and services.
Standardized Pathways
Partner with the HUB
The Community Care HUB initiative is made possible by funding from 1889 Foundation.
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