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.
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
Core Features of the HUB
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
Latest HUB News
Food insecurity is a concerning SDOH
Feeding America defines food insecurity “as a lack of consistent [...]
Establishing a Medical Home is important for HUB participants
Establishing a Medical Home for a participant is one of [...]