Pathways Community HUB Model of Care Coordination


The Rockville Institute’s Pathways Community HUB Certification Program (PCHCP) is the certifying agent of the Pathways Community HUB model of care coordination. This evidence-based HUB model is an accountable community-wide approach that effectively addresses risk factors, improves health and reduces cost. A Certified HUB ensures that those at greatest risk within a community are identified and that an individual’s medical, behavioral health, educational and social risk factors are addressed. Risk factors are addressed through the use of “Pathways” – a standardized process that identifies, defines, and resolves an at-risk individual’s needs by connecting the individual to community-based, culturally proficient services that are coordinated. The HUB complements Patient-Centered Medical Homes, Accountable Care Organizations, Health Information Exchanges, and other reform initiatives. Currently, HUBs have been deployed in more than 20 regions in the United States.

Why Certify?

Connecting at-risk individuals to timely, high-quality services that address biological, psychological, educational, and social needs requires expertise and investment. A Certified Pathways Community HUB provides the local infrastructure and accountability mechanisms to confirm those in need are connected to meaningful, culturally proficient, and comprehensive evidence-based services that are coordinated.

The HUB model of care coordination connects payment to the value of services provided and actual improvements in health outcomes. HUB Certification ensures an accountable and sustainable community care coordination system that leads to better health and lower costs.

What is a Standardized Pathway?

A Pathway is a standardized process that identifies, defines, and resolves an at-risk individual’s needs. Each Pathway represents one issue that is tracked through to completion and a measurable outcome.

What is a Certified HUB?

A Certified Pathways Community HUB is an efficient regional infrastructure that improves health outcomes and reduces costs by connecting those at-risk to quality community care coordination services.  Certified HUB serves as a regional clearinghouse that:

  1. “Registers” at-risk individuals;
  2. Connects an at-risk person to a community care coordinator;
  3. Monitors the quality, effectiveness and efficiency of community care coordination services; and
  4. Ties payments to health improvements and outcomes.

A Certified HUB results in less duplication, lower costs, improved health status, and fewer inequities.

PCHCP was made possible by the generosity of The Kresge Foundation, and in partnership with the Community Health Access Project, Inc., Communities Joined in Action, Georgia Health Policy Center, and the Rockville Institute.

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