Abstract: The present disclosure is directed to a computerized method, system and software application for coordinating medical care through a Pathways Community Hub (HUB). A Pathways Community Hub is a network of care coordination agencies which focuses its mission towards reaching individuals within the community having the greatest risk-factors through the deployment of service providers such as community care coordinators. The Pathways Community Hub finds at-risk individuals in need of medical, health-related or social services, treats identified risk factors and measures a patient's risk status over time. The goal of the Pathways Community Hub is to achieve a reduction of risk among patients through open communication and collaboration among service providers including medical service providers and community-based organizations and to reduce the overall cost of medical, health-related and social services over time within a region.

Abstract: The present disclosure is directed to a computerized method, system and software application for coordinating medical care through a Pathways Community Hub (HUB). A Pathways Community Hub is a network of care coordination agencies which focuses its mission towards reaching individuals within the community having the greatest risk-factors through the deployment of service providers such as community care coordinators. The Pathways Community Hub finds at-risk individuals in need of medical, health-related or social services, treats identified risk factors and measures a patient's risk status over time. The goal of the Pathways Community Hub is to achieve a reduction of risk among patients through open communication and collaboration among service providers including medical service providers and community-based organizations and to reduce the overall cost of medical, health-related and social services over time within a region.

Abstract: The present disclosure is directed to a computerized method, system and software application for coordinating medical care through a Pathways Community Hub (HUB). A Pathways Community Hub is a network of care coordination agencies which focuses its mission towards reaching individuals within the community having the greatest risk-factors through the deployment of service providers such as community care coordinators. The Pathways Community Hub finds at-risk individuals in need of medical, health-related or social services, treats identified risk factors and measures a patient's risk status over time. The goal of the Pathways Community Hub is to achieve a reduction of risk among patients through open communication and collaboration among service providers including medical service providers and community-based organizations and to reduce the overall cost of medical, health-related and social services over time within a region.