Community Care Hub

Community Care HUB2024-04-10T16:19:11+00:00

Community-Based Care Coordination in Cambria & Somerset Counties

In September 2020, the Center for Population Health launched the Community Care HUB (HUB) for Cambria and Somerset counties. Developed by the Pathways Community HUB Institute, the HUB model aims to impact health outcomes by addressing risk factors associated with poor health outcomes. A HUB is an organized, outcome focused, network of Care Coordination Agencies (CCAs) who hire and train community health workers (CHWs) and connect at-risk individuals to needed services. The HUB’s CCAs are Alleghenies United Cerebral Palsy Service Coordination and Beginnings, Inc.

The community health workers meet with participants face-to-face, preferably in their homes, then guide them through one or more of 21 Pathways designed to address their needs. The HUB model involves the collaboration of all community resources to reduce both medical and social barriers to care, like employment, housing and transportation, for individuals with complex health needs.

Core Features of the HUB


The most common barriers to health outcomes, such as employment, housing, and transportation, are categorized into 21 standardized pathways.

Community Health Workers

Community Health Workers (CHWs) partner with HUB participants to complete pathways. CHWs are employed by Care Coordination Agencies.

Care Coordination Agencies

Social service agencies, health clinics, and community-based organizations partner with the HUB to employ Community Health Workers.

Outcome-based Model

Payers and funders contract with the HUB to pay for the completion of pathways for HUB participants. Outcome-based contracts are directly linked with better health outcomes of HUB participants.

Community Care HUB Advisory Committee

  • Bruce Duke, MD
  • Carol Harding, RN, FCN, Moxham Lutheran Church/Certified CHW Trainer
  • Yvette M. Madison, MSW, Professor of Social Work, Pennsylvania Highlands Community College
  • Christy Berzonski, CCHW, Alleghenies United Cerebral Palsy
  • Gwen Msolomba, former CHW Supervisor/PhD candidate
  • Tammy Rhoades, CEO, Alleghenies United Cerebral Palsy
  • Jes Phillippi, Executive Director, Beginnings, Inc

The HUB is certified June 2022 through March 2024

The Community Care HUB (HUB) received its Level 1 Certification from the Pathways Community HUB Institute® (PCHI®). Receiving the certification means the HUB exceeded best practice standards and quality goals and is providing the best possible care coordination for participants.

Standardized Pathways

  • Adult Education
  • Developmental Referral
  • Employment
  • Family Planning
  • Food Security
  • Health Coverage
  • Housing
  • Immunization referral
  • Learning
  • Medical Home
  • Medical Referral
  • Medication Adherence
  • Medication Reconciliation
  • Medication Screening
  • Mental Health
  • Oral Health
  • Postpartum
  • Pregnancy
  • Social Service Referral
  • Substance Use
  • Transportation

Partner with the HUB

The Community Care HUB initiative is made possible by funding from 1889 Foundation.

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