Click Here to Make a Referral to the HUB

Community-Based Care Coordination in Cambria & Somerset Counties

In September 2020, the 1889 Jefferson Center for Population Health implemented 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 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.

Current HUB Eligibility

Click Here to Make a referral to the HUB

If you meet the eligibility criteria for EITHER category below, you qualify for this FREE program from the Community Care HUB. Anyone can make a referral to the HUB, including medical providers, social service providers, behavioral health providers, self referrals, and more.

Community Health Workers

A Community Health Worker (CHW) is a trusted individual who contributes to improved health outcomes in the community. CHWs serve the communities in which they reside or communities with which they may share ethnicity, language, socioeconomic status, or life experiences. HUB CHWs are employed by Care Coordination Agencies in the region who partner with the HUB. As of January 9, 2020, Community Health Worker Certification is now available in the state of Pennsylvania through the PA Certification Board.

According to the PA Certification Board, a CHW proactively:

  • builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy;

  • serves as a liaison between communities and health care agencies;

  • enhances community residents’ ability to effectively communicate with healthcare providers;

  • provides culturally and linguistically appropriate health education;

  • advocates for individual and community health;

HUB Care Coordination Agencies