||Great Rivers Hub will implement a system to bridge the gap between health care delivery and the social service sector for cost savings, improved population health outcomes, and increased client experience and engagement.
|The Current System
In our current system of healthcare and social services, services are provided to the individual and may be “siloed” in their provision of services. Imagine this family: a single mother is pregnant with her second child. Her four-year-old daughter is asthmatic, though undiagnosed, and they are living with grandma, a Type 2 Diabetic who smokes. Mom must not only manage contacts with multiple agencies for her own needs but also those necessary for her daughter’s health, and possibly for grandma, as well.
This approach can lead to individuals and families having to repeat their story to numerous providers in efforts to receive the care they need. It can also result in services being missed. Not only can this can be confusing and difficult to navigate, but it can also result in duplication of efforts by providers trying to meet the needs of the family.
|The Hub System
The Pathways Community Hub Model provides the opportunity to change our system to one that allows for a more efficient and effective way to provide holistic care to families in our community.
Instead of a family having to navigate multiple people from multiple agencies, the Community Care Coordinator assigned to the entire family identifies each individual’s risks, identifies outcomes to achieve (Pathways) to reduce their risk and navigates the family through the systems to obtain the services they need. This helps to streamline the acquisition of services for families and improves communication to service providers for more effective care.
Referrals may only be made through specific referral sites via an electronic portal connected to the Great Rivers Hub database. Other referrals may be possible through existing Care Coordination Agencies (CCAs) that are providing Community Care Coordination in the community.
Current Care Coordination Agencies
- Family & Children’s Center
- Independent Living Resources
- La Crosse County Health Department
- St. Clare Health Mission
- Gundersen Health System
- Mayo Clinic Health System
- La Crosse Community Foundation
- MCW Medical School – Advancing a Healthier Wisconsin Endowment
- Otto Bremer Trust
Please direct questions to Hub Director Lindsey Purl at firstname.lastname@example.org.