Community-Based Care Coordination in Cambria & Somerset Counties

The Community Care HUB is the major initiative of the Center for Population Health.

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, Beginnings, Inc, and The Women’s Help Center.

Current HUB Eligibility

If you meet the eligibility criteria for ANY category below, you may qualify for this FREE program from the Community Care HUB. Anyone can make a referral to the HUB, including medical providers, social service providers, behavioral providers, self-referrals, and more.

  • Pregnant people who live in Cambria or Somerset County and receive (or are eligible for) medical assistance and/or diagnosed with gestational diabetes

  • Parenting (0-24 months) living in Cambria or Somerset County and receives (or eligible for) medical assistance

  • Greater Johnstown Elementary School and Somerset Area School District families with social determinants of health needs

  • Individuals living in Cambria County who receive medical assistance with a mental health and/or substance use diagnosis

  • Housing insecure (direct referrals from The Community Help Center or Johnstown Housing Authority)

Core Features of the HUB

Pathways

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.

Partner with the HUB

CCA

A Care Coordination Agency (CCA) partners with the HUB to employ Community Health Workers who work with HUB participants.

Referral Partner

Connect with the HUB network as a referral partner so that you can make referrals for your clients or patients directly to the HUB.

DSP

Connect with the HUB network as a Direct Service Provider (DSP) for HUB participants to be referred to your agency for services.

Payer/Funder

Funding from insurers, government, and philanthropy is needed to ensure pathways coordination occurs for all.

Certification

The Community Care HUB (HUB) received its full Certification from the Pathways Community HUB Institute® (PCHI®). Achieving full certification signifies the Community Care HUB meets the stringent national standards for quality community care coordination services. Receiving a three-year term of recertification means the HUB has undergone a rigorous peer-reviewed process and has demonstrated unwavering commitment to providing measurable, accountable, and high-quality programs and services.

CHWs who are trained and have field experience may be eligible to apply for CHW certification through the Pennsylvania Certification Board. All community Care HUB CHWs either possess their CHW certification or are working toward it. Community Health Worker certification aligns with Pennsylvania CHW standards.

HUB Advisory Committee

  • Christy Berzonski
  • Stephanie Buck
  • Yvette Madison
  • April Carey
  • Barbara Duryea
  • Gwen Msolomba
  • Tammy Rhoades
  • Jes Phillippi
  • Tracy Shultz
  • Roxann Tyger

Resources

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