Pathways HUB Reentry Pilot (Spokane County, WA)

The Pathways HUB Reentry Pilot provides a community-based hub for care coordination to improve health outcomes, data collection and information sharing within the region. The hub is comprised of a network of community care coordinators employed by local non-profits and organizations.  The hub trains the care coordinators with evidence-based and best practice models called pathways. The hub employs a small team that supports the community care coordinators while maintaining the quality of care pathways and infrastructure. The hub partners with local care providers to make sure the care coordinators have current resources via a resources kit. The community care coordinators assist clients by helping them complete their assigned pathways. The client progress and care data is tracked and sent back to the hub via an integrated tablet-based platform. Providers can access real-time data to see how their clients are progressing on their pathways. Each pathway outcome/data can be compared across the care coordination spectrum. By having data readily availble assessments can be made to determine gaps in community resources which may be resulting in unfinished pathways. The hub partners with multiple funding options including regional health plans, government and philanthropy to help create sustainability and prevent the volitatilty of grants and contracts. With focus towards outcomes the hub helps get typically siloed help and social service providers working together to improve community health.