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.