Community Care 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
Individuals with conditions like diabetes and substance use disorder (direct referrals from insurers)

Make a Referral to the Hub

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

Community Health Workers (CHWs) partner with HUB participants to complete pathways. CHWs are employed by Care Coordination Agencies.

Care Coordination Agencies

Social service agencies, health clinics, and community-based organizations partner with the HUB to employ Community Health Workers.

Outcome-based Model

Payers and funders contract with the HUB to pay for the completion of pathways for HUB participants. Outcome-based contracts are directly linked with better health outcomes of HUB participants.