The Pathways Community HUB Model of care coordination promotes quality care, links payment to performance, and improves community care coordination, while addressing socioeconomic drivers of health. The Pathways HUB model identifies at-risk individuals; connects them to community care coordinators; monitors the quality, effectiveness and efficiency of services; and ties payments to health improvements and outcomes. The Pathways HUB model relies on community care workers to reach out to at-risk individuals in the community and assess their health, social, behavioral health, and economic needs. The identified, modifiable risk factors (e.g., preventive health care, housing, education, etc.) are addressed and tracked using standardized Pathways that utilize evidence-based and best practice interventions. The Pathways HUB model provides ongoing quality assurance that results in less duplication of services, lower costs, improved health status, and fewer health disparities.

Drs. Mark and Sarah Redding, who initially developed a set of standard pathways – essential for implementing community care coordination services – first created the HUB model in 2000. The Pathways Community HUB Institute upholds compliance to a set of national standards and certifies eligible community organizations through the Pathways Community HUB Certification Program (PCHCP) The PCHCP was first piloted in 2012 with funding from the Kresge Foundation.

The Georgia Health Policy Center (GHPC), the Rockville Institute, Communities Joined in Action, and the Community Health Access Project partnered to develop this national certification initiative. During the pilot phase, GHPC provided oversight, guidance, and project management support. Today, GHPC serves in a leadership capacity and as a senior advisor lending technical expertise and offering enhancements to the certification standards, assessment process, and training needs of HUBs to improve compliance with the standards.

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