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.
HUB Community Health Workers:
Find members of the priority population at greatest risk
Connect them to appropriate health and social service agencies
Remove barriers to obtaining care
Measure the results
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; and
identifies and helps enroll eligible individuals in federal, state, and local private or nonprofit health and human services programs.
Select HUB publications
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 partner with HUB participants to break down these barriers and complete the pathways that align most with the participant’s situation.
Community Health Workers – Community Health Workers (CHWs) serve as frontline public health workers who have a close understanding of the community served. This trusting relationship enables the CHW to serve as a link between health/ social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs are employed by Care Coordination Agencies.
Care Coordination Agencies – Organizations such as social service agencies, health clinics, and mental health agencies that partner with the HUB to employ Community Health Workers who work one-on-one with HUB participants.
Outcome-based model- Payers and funders contract with the HUB to pay for the completion of pathways for HUB participants. This value-based funding structure assures the financial sustainability of the HUB model and is directly linked with better health outcomes of HUB participants.
Social Service Referral
Partner with the HUB
Care Coordination Agency – A Care Coordination Agency (CCA) partners with the HUB to employ Community Health Workers who work with HUB participants. The HUB Review Committee will select up to three (3) organizations to become CCAs. The HUB will support these CCAs to hire, train and employ two (2) HUB CHWs each. Recognizing that the Pathways Community HUB model uses an outcome-based payment methodology, the HUB will support organizations to make the transition to this new payment system.
Community Care HUB Care Coordination Agencies:
Other HUB Partnership Opportunities
Referral Partner – Connect with the HUB network as a referral partner so that you can make referrals for your clients or patients directly to the HUB.
Direct Service Provider – Connect with the HUB network as a direct service provider for HUB participants to be referred to your agency for services.
Payer/Funder – Funding from insurers, government, and philanthropy is needed to ensure pathways coordination occurs for all people.
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:
Latest HUB News
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 Jefferson Center for Population Health, established through a partnership between 1889 Foundation and the Jefferson College of Population