Hubs are a popular model of care in which a centralized entity provides administrative, clinical, and/or fiscal support and resources for a network of community-based organizations (CBOs), including those with community health workers (CHWs) offering social and health services.
Community hubs, or hubs, can look very different and operate in many ways. Sometimes, hubs include member organizations across common geographic regions, demographics, such as a rural or LatinX population, or health concerns, such as maternal or mental health. Together, participating organizations can collaboratively address social drivers of health, fostering a more holistic approach to supporting clients.
How hubs support community-based organizations providing community services
Hubs serve as centralized points that coordinate and deliver a wide range of health services while consolidating administrative support to the community providers participating in the hub. This can include tracking contracts with funders or healthcare organizations, overseeing fiscal operations, handling client referrals, ensuring compliance, and managing technology, information security, data, and reporting. Additionally, hubs can coordinate care across member organizations, collaborate to boost contract negotiating leverage, and share resources and best practices to maximize the impact of collective efforts. This allows organizations to focus on increasing their impact and support of clients rather than navigating paperwork and reports. Hubs may also streamline care by integrating various aspects of medical and social support to improve overall health outcomes in a community.
In many states, the community services provided to clients are also eligible for reimbursement through a Medicaid community health worker benefit, such as care coordination and education.
Care coordination
Hubs can provide a range of integrated care services, such as primary care, mental health services, chronic disease management, and preventive care, in a central location or through a network of connected CBOs.
They also promote collaboration between healthcare providers, social workers, and community organizations, ensuring that care is holistic and considers social drivers of health, such as safe housing, access to nutritious food, and employment. They also serve as a central point for referrals to specialists, hospitals, or other services, making it easier for clients to navigate complex healthcare systems.
Access to care
By being locally situated by region or city and interest area, hubs improve access to care, especially in underserved or rural areas where health services may be scarce. Since hubs can include CBOs with local community health workers, they often cater to the specific needs of the local population, including offering services in multiple languages, providing culturally sensitive care, connecting clients to nearby resources, and addressing the unique health challenges faced by the community.
They also reduce logistical barriers, such as transportation and financial costs by partnering with community-based organizations within or outside their network.
Preventive health services and education
Many hubs are actively engaged in both intervention and prevention measures, such as community outreach and education, through the CBOs and CHWs in their network.
Such activities can take place in group settings or one-on-one interactions to help clients take action on preventative measures, such as vaccinations, health screenings, annual wellness visits (AWV), and topical fluoride varnishes or simply providing health education. Preventative activities can also bring the community together through workshops, support groups, or health fairs. Both seek to raise awareness about health issues and educate clients about healthy living to reduce the incidence of disease and promote healthier lifestyles.
Clinical support
Inherently collaborative, hubs often emphasize a client-centered approach, connecting community members to information and services within complex healthcare systems to help them address or overcome health or social challenges. They also work with clients to set health goals, manage their conditions, and navigate the health system effectively.
For clients with chronic conditions like diabetes, heart disease, or asthma, CHWs and CBOs within hubs provide continuous care, support, and education to help them manage their health alongside their traditional clinical provider. This includes monitoring, lifestyle advice, medication management, and regular check-ins that ensure that clients can stick to their care plans and reduce the likelihood of costlier interventions or even hospital admissions.
Many hubs also integrate mental health services, such as counseling, psychiatric care, and addiction support, recognizing that behavioral health is a critical part of overall well-being and health—regardless of the demographic they serve.
Data collection and public health monitoring
Along with supporting individual CBOs, hubs are well-positioned to collect data on the health needs and outcomes of the community, helping public health officials track and understand health trends or understand the impact of interventions.
This data can inform policy decisions at local, state, or regional levels, ensuring that resources are directed where they are most needed.
Leveraging technology for community care
How Pear Suite supports the hub care model
The hub model is growing in popularity as more community-based organizations engage in cross-sector partnerships with the healthcare ecosystem.
To provide consistent care and secure funding and reimbursement, especially in California where the Medi-Cal community health worker benefit is available, Binational initially started using the Pear Suite care navigation platform to support individual operations and streamline billing. They’ve been able to scale up their efforts, bringing in additional community organizations to expand impact.
A care navigation system designed to support hubs eased the transition, allowing them to easily shift to supporting several individual CBOs and their clients. The platform standardizes data collection by creating a method to consistently capture and track information about individual client needs, the services provided, and the outcomes.
This was similar to how the Kūpuna Collaborative’s Kūpuna Support Navigator Program in Hawai’i has leveraged Pear Suite’s hub functionality. While all four hub member groups in this program supported different older adult clients to address different social drivers of health on different islands, they utilized unified screening and impact analysis tools, tracking consistent progress and outcome measures for thousands of individuals.
And because workflows are standardized across individual CBOs within a hub, everyone stays on the same page to efficiently and effectively coordinate and address client needs to improve care outcomes. Individual and CBO-level data can be visualized and measured through standard reports, which can be used to understand the impact of interventions to apply for funding, for example, and make data-driven decisions, such as expansion.
The Pear Suite hub
Understanding the value of collaborative and community-focused care, Pear Suite employs more than 700 community health workers through the Pear Suite provider network.
These tech-enabled CHWs serve clients referred to them by health plans and organizations to support value-based care models. They use the Pear Suite platform to collect and manage client data for reporting purposes as well as track referrals, education, and other services provided to clients.
Learn more about how Pear Suite supports hubs by scheduling with a partnership expert.
