Community-Based Care Coordination
Pathways Community Hub
The Pathways Community HUB promotes care coordination across the continuum of health for Medicaid beneficiaries by identifying, treating, and measuring risk factors that affect individual health. This model of community-based care coordination aims to ensure those with complex health needs are connected to the interventions and services needed to improve and manage their health.
Physical health, behavioral health, and social support systems historically do not coordinate their services well. Community CarePort (CPAA’s Pathways HUB) provides “Care Traffic Control” to break down silos, coordinate care, and improve health. Our Care Coordinators work individually with clients to identify risk factors from all aspects of a client’s life. The Care Coordinators help clients access the services they need, including health care, housing services, education, employment, and more.
This is 1 of 6 program areas chosen by CPAA as part of the Washington Healthcare Authority's (WA HCA) Medicaid Transformation Projects (MTP), which began in 2017. In 2022, WA HCA, with approval from CMS, granted CPAA a Year 6 extension on the original 5-Year Waiver. This work is supported and directed by CHOICE Regional Health Network.
Call 1-800-662-2499 for a referral
Physical health, behavioral health, and social support systems historically do not coordinate their services well. Community CarePort (CPAA’s Pathways HUB) provides “Care Traffic Control” to break down silos, coordinate care, and improve health. Our Care Coordinators work individually with clients to identify risk factors from all aspects of a client’s life. The Care Coordinators help clients access the services they need, including health care, housing services, education, employment, and more.
Pre-referral checklist:
Our priority population include those who can answer YES
to all three of these questions:
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Does the person have a behavioral health concern?
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Mental health
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Substance use
2. Is there an additional concern?
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Pregnancy
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Chronic disease
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Co-occurring behavioral health
3. Are there additional risk factors?
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Housing insecurity
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Recent release from hospital
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Frequent need to use 911
Any person who can answer yes to these questions is
eligible to work with a Care Coordinator.
How the Community Careport HUB works:
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Clients connect with Community CarePort by calling the referral line (800-662-2499) or by being referred by someone else.
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The HUB assigns the client to a Care Coordinating Agency.
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Care Coordinators help the client prioritize goals, access services, and become more engaged in their own well-being.
Social Determinants of Health and Care Coordination:
Care coordination services are an important aspect of care delivery because they connect people to resources that support the broader social determinants of health. Community CarePort specifically assesses all aspects that contribute to wellness and provides standardized Pathways that help people access and obtain the help they need. Examples include education, employment, and housing. The Pathways model also emphasizes that clients should set their own goals and be supported by care coordinators. This means that services are driven by the specific things that people need the most to make improvements in their own lives.
