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Connecting Those at Risk to Care: The Quick Start Guide to Developing Community Care Coordination Pathways


This Quick Start guide complements Connecting Those at Risk to Care: A Guide to Building a Community “HUB” To Promote a System of Collaboration, Accountability, and Improved Outcomes, published in 2010 by the Agency for Healthcare Research and Quality (AHRQ). That 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.

This guide is a reference and resource for public and private stakeholders engaged in improving the system for identifying and connecting at-risk individuals within a community to appropriate health and social services. The target audience includes all those involved in the design, implementation, and financing of care coordination services.

This guide gives an overview of the process for developing a community HUB and reviews the tools and resources needed to develop a HUB using pathways. It is organized into the following sections:
  • Overview
  • Why create a community HUB and pathways?
  • A quick guide to creating and using a community HUB and pathways
  • Examples of six core pathways
  • Other resources
  • Pathways compendium
  • Exhibits
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Community Care Coordination Learning Network

Funding Sources

Agency for Healthcare Research and Quality

QualityTool Topic



  • Release Date: 02/2012
  • Original Summary: 02/2012
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Last updated: March 07, 2012.