Community-Based Care Coordination in Cambria & Somerset Counties
According to the County Health Rankings, only about 20% of the modifiable contributors to a person’s overall health is determined by clinical care. A coordinated approach is needed to address the other 80% of factors that influence a person’s health — socioeconomic factors and health behaviors, otherwise known as the “social determinants of health.” Research has shown that community-based care coordination that addresses the social determinants of health improves health outcomes of at-risk populations. In 2019, Cambria County ranked 65th out of 67 counties in the Commonwealth of PA for health outcomes; Somerset County ranked 31st for health outcomes.
The 1889 Jefferson Center for Population Health and the greater community is working to develop 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.
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. 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;
provides guidance and social assistance to community residents;
enhances community residents’ ability to effectively communicate with healthcare providers;
provides culturally and linguistically appropriate health education;
advocates for individual and community health;
provides referral and follow-up services or otherwise coordinates care;
identifies and helps enroll eligible individuals in federal, state, and local private or nonprofit health and human services programs.
Core Features of the HUB
Learn More about the HUB model
Select HUB Publications
Social Service Referral
Partner with the HUB
If your organization is interested in partnering with us as a HUB referral partner, direct service provider, payer, or in another way, please get in touch!
The Community Care HUB initiative is made possible by funding from the 1889 Foundation.
Latest HUB News
Click here to read June's Health Matters article in the Tribune Democrat which features a discussion between Jeannine McMillan, 1889 Jefferson Center for Population Health; Dr.
1889 Jefferson Center for Population Health announces Care Coordination Agencies to join Community Care HUB; Introduces Newly Certifiable Workforce to Cambria/Somerset Counties JOHNSTOWN – The 1889