September 1, 2021 marked the one-year anniversary of the Community Care HUB. We are grateful to HUB Care Coordination Agencies – Alleghenies United Cerebral Palsy, Beginnings, Inc., & Community Action Partnership of Cambria County – who became Care Coordination Agency partners of ours over a year ago. Needless to say, starting a home-visiting program during a pandemic made things challenging for Community Health Workers, but they adapted the model with ease.

Over the past year, the HUB has reached many milestones, including:

  • All Community Health Workers became certified Community Health Workers through the PA Certification Board
  • The HUB expanded its participant population to include families of the Greater Johnstown School District
  • Gateway Health Plan became an official partner of the HUB to improve the health of their members
  • In May 2021, the HUB reached the milestone of serving over 100 participants in the program

This past year, the six HUB Community Health Workers (CHWs) have opened a total of 894 Pathways for their participants and logged 400 participant visits. Pathways are barriers to positive health outcomes such as housing, food security, transportation, or mental health. They’ve also made a total of 301 referrals to local social service agencies to get their participants connected to the resources they need. Additionally, CHWs utilized 155 learning modules to educate their participants on a variety of topics ranging from safe infant sleep to COVID-19 vaccine hesitancy. Last but not least, 27 infants have been born to HUB participants over the past year!

The Community Care HUB follows the nationally-recognized and evidence-based Pathways Community HUB model developed by the Pathways Community HUB Institute. A HUB is an organized, outcome focused, network of Care Coordination Agencies (CCAs) who hire and train community health workers (CHWs) to reach out to those at greatest risk. The HUB helps to coordinate community resources to reduce the medical, behavioral and social barriers to care.

Pregnant women living in Cambria or Somerset County are eligible for a referral to the HUB if they meet one or both of the following criteria: 1) receiving or eligible for Medical Assistance 2) diagnosed with gestational diabetes. Additionally, families of students attended Johnstown Elementary School experience barriers with attendance and social determinants of health are also eligible for referral. Those referred will be connected to a Community Health Worker (CHW) who will link them to existing community resources, such as housing, transportation, child care, and medical providers. There is no cost for services.

Anyone can refer an eligible individual to the HUB with their consent, including medical providers, social service agencies, community organizations, and self-referrals. To refer someone or to learn more about the Community Care HUB, visit:, call 814-535-5156 or email