North Sound Community HUB
What is a Community HUB?
The North Sound Accountable Community of Health (NSACH) is launching the North Sound Community HUB based on the Pathways Community HUB model. This model is a strategy for community-based care coordination and is made up of a HUB and Care Coordination Agencies (CCAs). CCAs provide care coordination for individuals in the community who are most at risk for poor health and social outcomes. In the delivery of care coordination services, the Care Coordinator identifies and addresses risk factors that are the primary sources of poor health, physical and behavioral, and social outcomes. Risk factors are assigned to a pathway and these pathways guide care coordination through to a measurable outcome; there are 20 pathways, some examples include housing, employment, medical referral, behavioral health, medication management, and social service referral. The care coordination services information is entered into the HUB (centralized system), which, along with the whole person focus, facilitates reduction in fragmentation and duplication in services and improves accountability and outcomes.
What is Compass Health’s role in the North Sound Community HUB?
Compass Health will be one of three Care Coordination Agencies initially and will be serving Snohomish County to start.
- Medicaid recipient or Medicaid eligible; AND
- Individual resides in Snohomish, Skagit, San Juan, or Whatcom counties; AND
- Individual is in need of care coordination services and is not receiving care coordination services elsewhere; AND
- Individual is experiencing a behavioral health concern, mental health or substance use (includes self-identified concerns); AND
- Individual meets one or more of the following criteria:
- Experiencing a chronic physical health condition
- Woman of child-bearing age
- Homeless or experiencing housing insecurity (imminently homeless)
- Multiple emergency department visits and/or inpatient stays in the last 6 months
- Multiple instances of incarceration in the last year