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Community Care Coordination at a Glance
Community Care Coordination


The Community Care Coordination at a Glance page features programs that have implemented models of care that integrate various health and social support services within a community. Community care coordination builds upon the American Academy of Pediatrics’ recommendation to improve quality of care by coordinating needed health and social services.1 This collaboration of community resources aims to improve the health of individuals, particularly those from vulnerable populations, by alleviating both medical and social barriers to care, including employment, housing, and transportation.

Innovations Addressing Community Care Coordination

In March 2008, the Community Care Coordination Learning Network (CCCLN) was launched with a focus on the Pathways Model of community care coordination, which was created by Drs. Mark and Sarah Redding of Mansfield, Ohio. Similar to the general purposes of other AHRQ-sponsored communities of practice and learning networks, the CCCLN provided learning and networking opportunities among the AHRQ Health Care Innovations Exchange users.

During its tenure, the CCCLN was a valuable resource for:

  • Connecting potential adopters of the Pathways Model;
  • Facilitating the exchange of information and translation of knowledge through presentations, group meetings, standard data collection and reporting efforts, and product development activities;
  • Fostering networking and learning about issues affecting community care coordination and its effect on vulnerable populations, whom are considered high risk for chronic health conditions; and
  • Developing community-based strategies designed to identify at-risk populations within local communities, create pathways that link these populations to health care and social services, and measure outcomes.

The CCCLN originated with its champions – Drs. Mark and Sarah Redding – and grew to a network consisting of 17 hub directors, representing 16 distinct community hubs in 10 states. As the network evolved, members engaged in community-based participatory research activities and developed work products such as a guide that provides a step-by-step process to build and sustain an infrastructure to support the delivery of community care coordination services.

In September 2011, the CCCLN transitioned from an AHRQ Health Care Innovations Exchange-sponsored learning network to the Center for Pathways Community Care Coordination at the Rockville Institute for the Advancement of Social Science Research. External Web Site Policy

Please visit Community Care Coordination at a Glance for regular updates regarding programs and quality tools.

Additional Resources and References
  1. Care Coordination: Integrating Health and Related Systems of Care for Children With Special Health Care Needs American Academy of Pediatrics: Committee on Children With Disabilities 1999;104/4/978.pdf External Web Site Policy (Adobe Reader is required to view or print the PDF. Download a free copy here. External Web Site Policy)
Community Care Coordination Profiles
Alliance Creates Community Health Workers’ Scope of Practice, Training Curriculum, Certificate Program, and Reimbursement Strategy, Expanding Their Integration Into the Health System to Reduce Health Disparities
Outreach Workers Connect Low-Income Individuals Living in Rural Areas to Home- and Community-Based Services, Reducing Costs and Nursing Home Placements
Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health
Care Coordination, Peer Support, and Discretionary Fund Improve Quality of Life and Reduce Costs for Adults with Serious Mental Illness
Related QualityTools
NewPatient-Centered Medical Home
This Web site from the American Academy of Family Physicians provides step-by-step project plans and tools to build a patient-centered medical home. It also includes a checklist for practices to determine if they are already a patient-centered medical home.
Connecting Those at Risk to Care: A Guide to Building a Community 'HUB' to Promote a System of Collaboration, Accountability, and Improved Outcomes
Connecting Those at Risk to Care: A Guide to Building a Community "HUB" to Promote a System of Collaboration, Accountability, and Improved Outcomes
This guide is intended to help improve the system by which at-risk individuals within a community are identified and connected to appropriate health care and social services.
NewConnecting Those at Risk to Care: The Quick Start Guide to Developing Community Care Coordination Pathways
This manual describes a "Pathways Community HUB," a new type of infrastructure that provides the beginning tools and strategies needed to ensure that at-risk individuals are served in a timely, coordinated manner.
Pathways: Building a Community Outcome Production Model
Pathways: Building a Community Outcome Production Model
This manual, developed by the Community Health Access Project (CHAP), provides detailed information and implementation guidelines for the Pathways Model, a recognized model of community-based care coordination.

Last updated: March, 20 2013.