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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. The audience includes a diverse set of public and private stakeholders involved in coordinating care for at-risk individuals. This guide may be of interest to Federal, State, and local governmental agencies and community-based organizations, such as safety net clinics, hospitals, public health departments, and charitable organizations.

The guide contains the following:
  • Background regarding current challenges in serving at-risk populations
  • Addressing the problem through a Pathways Community HUB
  • A step-by-step guide to building a Pathways Community HUB, including planning, creating tools and resources, and launching the HUB
  • Moving forward after implementation
  • Links to related tools and resources
Links to the Tool:
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Community Care Coordination Learning Network

Funding Sources

Agency for Healthcare Research and Quality

QualityTool Topic



  • Release Date: 09/2010
  • Original Summary: 09/2010
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QualityTool Classification
Patient Care Process:

Last updated: September 15, 2010.