Addressing the Problem Through a Pathways Community HUB

A Pathways Community HUB can support the "find-treat-measure" approach outlined earlier by providing the infrastructure to identify those at risk and coordinate and monitor the services provided. The HUB's primary goal is to ensure the timely provision of appropriate, high-quality, cost-effective, evidence-based services that will have a meaningful impact on those served.

By focusing on those at greatest risk, the intent of the HUB is to bring greater equality in service delivery and health outcomes. Those at risk may then achieve a similar level of access and disparity reduction.

The HUB brings public and private community stakeholders—including health and social service providers, elected officials, businesses, and representatives of the at-risk population being served—together to determine local health needs and create the appropriate support, services, and interventions most effective for addressing those needs. Through coordination, communication, and built-in incentives, the HUB strives to increase the effectiveness of care coordination services across multiple programs to ensure that those at risk are identified and connected to care in a timely manner.

To accomplish these goals, the HUB serves as a central clearinghouse that "registers" at-risk individuals and coordinates the care they receive, making sure that biological, psychological, and social needs are met. The HUB does not support any single agency, but rather strengthens and supports all health and social service providers in the region. The HUB eliminates duplication and waste and provides needed support services.

A Pathways Community HUB includes a system support structure that helps local agencies work as a team to focus on those at risk, ensure that they connect to both health and social services, and measure outcomes. Tracking important process measures, impact measures (confirmed connection to care), and outcomes across the community system of care supports efforts to improve quality, eliminate duplication, and increase efficiency. The HUB serves as an important part of regional infrastructure to support local agencies and funders in effectively serving those at greatest risk.

Rather than allowing care coordination providers to function in isolated duplicated silos, the HUB focuses them on working together as a team to reach those at greatest risk and ensure that they connect to critical prevention and early treatment, reducing cost and disparity. In short, the HUB connects those who are vulnerable with community resources and holds providers, practitioners, employers, families, and individuals accountable for the outcomes achieved.