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Care Coordination

Better Health Pathways HUB

 

 

The Better Health Pathways HUB has connected thousands of Cuyahoga County residents to care and resources that help them overcome health and social barriers such as insurance eligibility, medical needs, food insecurity, transportation, housing stability, employment and more. Our Pathways HUB receives referrals from Managed Care Organizations (Payers) and Community-Based Organizations (CBOs) to enroll their members, patients and clients, so they can receive the care they need. The clients we serve are Adults (18+), Pediatrics (<17), and Pregnant people.

We use a care coordination model that connects individuals with complex health and social needs to community-based services through trusted community health workers (CHWs). Each person in need is guided along proven ‘pathways’—like housing, food access, or medical care—until their needs are fully addressed. It’s a results-driven system that improves health, reduces disparities, and ensures accountability by paying for outcomes, not just services. It’s a smart, community-centered way to close gaps and build healthier populations.

Our CCA partners include:

 

CHWs work with clients to address health and social "pathways"

  • Adult Education

  • Developmental Referral

  • Employment

  • Family Planning

  • Food Security

  • Health Coverage

  • Housing

  • Immunization Referral

  • Learning

  • Medical Home

  • Medical Referral

  • Medical Adherence

  • Medical Reconciliation

  • Medical Screening

  • Mental Health

  • Oral Health

  • Postpartum

  • Pregnancy

  • Social Service Referral

  • Substance Use

  • Transportation

Contact Information