Connecting Those at Risk to Care: A Guide to Building a Community "HUB" to Promote a System of Collaboration, Accountability, and Improved Outcomes
by Laura Brennan, MSW; Drs. Sarah and Mark Redding; and the AHRQ Community Care Coordination Learning Network (CCCLN)
This guide is intended to help improve the system by which at-risk individuals within a community are identified and connected to appropriate health care and social services. The audience includes a diverse set of public and private stakeholders involved in coordinating care for at-risk individuals. This guide may be of interest to Federal, State, and local governmental agencies and community-based organizations, such as safety net clinics, hospitals, public health departments, and charitable organizations.
Download this Guide as a PDF (1.02MB) (Adobe Reader is required to view or print the PDF. Download a free copy here. )
Listen to Innovator Stories about the Guide
Judith Warren, MPH
Why the HUB Approach to Integration and Care Coordination?
Listen to the audio file
Transcript (HTML)
Jim Walton, MD
Lessons Learned from Creating a Community HUB
Listen to the audio file
Transcript (HTML)
Flash Player Download
Contents:
Introduction and Purpose
Background: The System's Difficulty Identifying and Connecting At-Risk Populations to Care
Inadequacy of Current Efforts
Addressing the Problem Through a Pathways Community HUB
A Step-by-Step Guide to Building a Pathways Community HUB
Phase One: Planning the HUB
Step 1: Form a Planning Group
Step 2: Create a New Umbrella Agency or Designate a Lead Agency
Step 3: Conduct a Complete Community Needs Assessment
Step 4: Discuss Sustainability Issues and Develop a Plan To Secure Funding
Phase Two: Creating Tools and Resources for the HUB
Step 5: Build “Pathways” or Other Benchmarks To Create Accountability
Step 6: Create Supporting Tools and Documents for Care Coordinators
Step 7: Create Incentives Tied to Desired Outcomes
Step 8: Develop Systems To Track and Evaluate Performance
Phase Three: Launching the HUB
Step 9: Hire HUB Staff
Step 10: Train Staff at Participating Agencies
Step 11: Conduct a Community Awareness Campaign
Moving Forward After Implementation
Conclusion
References
Appendix
This section includes sample pathways, forms, and other resources to assist communities in building a hub. Links to additional resources that may be useful are also provided.
|