Community Care HUB2022-05-19T12:21:52+00:00
Make a Referral to the Hub

Community-Based Care Coordination in Cambria & Somerset Counties

In September 2020, the 1889 Jefferson 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 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

If you meet the eligibility criteria for ANY category below, you may 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 providers, self-referrals, and more.

  • Pregnant women who live in Cambria or Somerset County and receive (or are eligible for) Medical Assistance.

  • Pregnant women who live in Cambria or Somerset County and are diagnosed with Gestational Diabetes.

  • Greater Johnstown Elementary School families with social determinants of health needs.

  • Somerset Area School District families with social determinants of health needs

Make a Referral to the Hub

Core Features of the HUB

Learn More about the HUB model

Academy Health
Health Affairs
Agency for Healthcare Research & Quality
More HUB Published Research

Standardized Pathways

  • Adult Education

  • Developmental Referral

  • Employment

  • Family Planning

  • Food Security

  • Health Coverage

  • Housing

  • Immunization referral

  • Learning

  • Medical Home

  • Medical Referral

  • Medication Adherence

  • Medication Reconciliation

  • Medication Screening

  • Mental Health

  • Oral Health

  • Postpartum

  • Pregnancy

  • Social Service Referral

  • Substance Use

  • Transportation

Partner with the HUB

The Community Care HUB initiative is made possible by funding from 1889 Foundation.

Latest HUB News

Go to Top