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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

by Laura Brennan, MSW; Drs. Sarah and Mark Redding; and the AHRQ Community Care Coordination Learning Network (CCCLN)

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.

 Download this Guide as a PDF (948KB) (Adobe Reader is required to view or print the PDF. Download a free copy hereExternal Web Site Policy)

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Judith Warren, MPH
Why the HUB Approach to Integration and Care Coordination?

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Jim Walton, MD
Lessons Learned from Creating a Community HUB

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Introduction and Purpose

Background: The System's Difficulty Identifying and Connecting At-Risk Populations to Care

Inadequacy of Current Efforts

Addressing the Problem Through a Pathways Community HUB

A Step-by-Step Guide to Building a Pathways Community HUB

Phase One: Planning the HUB
Step 1: Form a Planning Group
Step 2: Create a New Umbrella Agency or Designate a Lead Agency
Step 3: Conduct a Complete Community Needs Assessment
Step 4: Discuss Sustainability Issues and Develop a Plan To Secure Funding

Phase Two: Creating Tools and Resources for the HUB
Step 5: Build “Pathways” or Other Benchmarks To Create Accountability
Step 6: Create Supporting Tools and Documents for Care Coordinators
Step 7: Create Incentives Tied to Desired Outcomes
Step 8: Develop Systems To Track and Evaluate Performance

Phase Three: Launching the HUB
Step 9: Hire HUB Staff
Step 10: Train Staff at Participating Agencies
Step 11: Conduct a Community Awareness Campaign

Moving Forward After Implementation



This section includes sample pathways, forms, and other resources to assist communities in building a hub. Links to additional resources that may be useful are also provided.

Last updated: September 22, 2010.