Community Care Coordination Systems

Connecting Patients to Community Services

This issue brief explains the core functions of community care coordination systems and presents a checklist of the critical success features that should be in place in communities that want to move forward. A spotlight on the Pathways Community HUB model provides more detail about how a community care coordination system operates on the ground.

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Community care coordination systems offer an opportunity to address social determinants of health needs more effectively, improve outcomes, reduce duplication and, thereby, lower costs. This brief describes the key functions of successful community care coordination systems and lays out the key strategies for success in developing them - from adequate staffing and leadership to the importance of community resources and partner involvement. A deep dive on the Pathways Community HUB model illustrates how a community care coordination system is intended to work on the ground. 

This brief is part of a series on Medicaid Payment Strategies for Financing Upstream Prevention resulting from an AcademyHealth Payment Reform for Population Health initiative collaboration with Nemours Children’s Health System. See the rest of the series here.

Jennie Bonney, M.P.H.

Independent Consultant

Jennie Bonney, M.P.H., is an independent health policy consultant focusing on Medicaid and the State Children'... Read Bio

Debbie I. Chang, M.P.H.

Senior Vice President, Policy and Prevention - Nemours Children’s Health System

Debbie I. Chang, M.P.H, is Senior Vice President of Policy and Prevention and a Corporate Officer for Nemours ... Read Bio