Community-based Care Coordination: Pathways Community HUB
According to the National Institute for Health Care Management Foundation, 5% of the population account for 50% of healthcare spending in the United States.
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.
Video produced by our partners in health, Better Health Together, http://www.betterhealthtogether.org/. All rights reserved © Better Health Together, 2018
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.
North Central’s Pathways Community HUB is currently lead by Action Health Partners.
Pathways Community HUB Advisory Group meeting materials can be found here.