The Pathways Community HUB Manual is designed as a guide to help those interested in improving care coordination to individuals at highest risk for poor health outcomes. The Pathways Community HUB (HUB) model is a strategy to identify and address risk factors at the level of the individual, but can also impact population health through data collected.
The most important functions of the Pathways Community HUB are to:
- Centrally track the progress of individual clients (to avoid duplication of services and identify and address barriers and problems on a real-time basis).
- Monitor the performance of individual workers (to support appropriate incentive payments).
- Improve the health of underserved and vulnerable populations.
- Evaluate overall organizational performance (to support appropriate payments, promote ongoing quality improvement, and help in securing additional funding).