The Pathways Community HUB Manual is a guide to improving coordination of care for individuals at highest risk of poor health outcomes. The HUB model provides a strategy for identifying and addressing risk factors at the individual level. Through data collected as part of the strategy, the model can also have an impact on population health. The intended audience for the manual is a diverse set of public and private stakeholders involved in coordinating care for at-risk individuals. Among key stakeholders are Federal, State, and local governmental agencies; community-based organizations; safety net clinics; hospitals; public health departments; and charitable organizations.

The manual contains the following sections:

• Introduction and purpose
• The broken business model of care coordination
• A way to solve the problem: Pathways Community HUB
• Summary of the Pathways Community HUB model
• Elements of a HUB
• A step-by-step guide to building a Pathways Community HUB
• Links to related tools and resources