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

Developed by: Community Care Coordination Learning Network

This quick start 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 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.

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CCCLN Quick Start Guide Work Group



Why Create a Community HUB and Pathways?
Reason #1: To Promote the Goals of Health Care Reform
Reason #2: To Close the Nation’s Cost and Quality Gap by Paying for Value, Not Volume

A Quick Guide to Creating and Using a Community HUB and Pathways
Key Elements of an Effective Community HUB
A Step-by-Step Process for Using a Pathway

Examples of Six Core Pathways
Core Pathway 1: Medical Home
Core Pathway 2: Medical Referral
Core Pathway 3: Social Service Referral
Core Pathway 4: Health Insurance
Core Pathway 5: Medication Assessment
Core Pathway 6: Pregnancy

Other Resources

Appendix A: Pathways Compendium

Exhibit A-1: Sample Demographic and Referral Form
Exhibit A-2: Sample Care Planning Checklists
Exhibit A-3: Followup Adult Checklist
Exhibit A-4: Examples of Reports for the Community HUB and Participating Agencies

Last updated: February 29, 2012.