The Center for Pathways Community Care Coordination (CPCCC) is a collaborative partnership between the Rockville Institute and the Community Health Access Project (CHAP). Its mission is to reduce disparities in health outcomes and health care among vulnerable at-risk populations.

This mission is accomplished by promoting systemic improvements in access to quality health care and social services through the adoption of evidence-based community care coordination practices.


The Center for Pathways Community Care Coordination (CPCCC) had its origins in the Community Care Coordination Learning Network (CCCLN), which was established in March 2008 as part of the Agency for Healthcare Research and Quality’s Health Care Innovations Exchange. The Innovations Exchange offers visitors a wealth of information about health service delivery innovations that support quality improvement and disparities reduction efforts for diverse populations in a variety of settings.

The CCCLN’s mission was to improve the health status of underserved populations at high risk for disparities in health and health care. Unlike provider-based care coordination, community care coordination aims to reduce disparities by working with a diverse set of individuals and organizations in the community.

In April 2011, CHAP and the Rockville Institute collaborated to form a new entity. CHAP’s Mark Redding, MD, had been a champion of CCCLN, and the collaboration transferred the CCCLN’s mission to the National Center for Community Care Coordination. The entity has since been renamed to Center for Pathways Community Care Coordination to better reflect its focus on the Pathways Model of community care coordination.

The advantage of this type of coordination is that it includes other services that affect a patient’s health status, such as social and other support services that are critical for accessing health care.

Pathways Community HUBs

With help from Laura Brennan, Wende Baker, Mary Overall, and Jan Ruma, the CCCLN grew to a network of 17 directors, representing 16 distinct Pathways Community HUBs in 10 states. For more information, visit Community Care Coordination at a Glance on the Innovations Exchange.

The CPCCC partnership between the Rockville Institute and CHAP will help sustain a vibrant and diverse network of Pathways Community HUB leaders and stakeholders dedicated to systemic health care reform and reduction of disparities in health outcomes and health care.

The HUBs are independent entities with individual charters, but their collective participation in CPCCC activities supports the development and sharing of innovative approaches for providing effective community care coordination services.

Defining Community Care Coordination

Based on the idea that community care coordination represents an effort to influence a wide variety of factors in a patient’s environment, the Center for Pathways Community Care Coordination (CPCCC) has adopted the following definition to guide its work:

Community care coordination is the process of

  • Identifying and engaging individuals within their community home setting
  • Assessing their health and social needs
  • Connecting them to the health and/or social services they need

The more general term “care coordination” has been defined in many ways by researchers focusing on the concept from the perspectives of disease management, case management, care management, transitional care, or other domains.

AHRQ’s Analysis

In Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 7—Care Coordination, Structured Abstract, the Agency for Healthcare Research and Quality (AHRQ) identified more than 40 definitions of care coordination and related terms. (Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 7—Care Coordination, Structured Abstract. Publication No. 04(07)-0051-7, June 2007. http://www.ahrq.gov/clinic/tp/caregaptp.htm)

The AHRQ's analysis used a working definition of care coordination as "the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services." Organizing care involves the marshaling of personnel and delivery of health care services.

Overcoming Barriers

Community care coordination works to assist individuals navigate and overcome barriers they encounter between their home and a wide range of institutional structures, such as clinics, hospitals, and human service agencies (e.g., public assistance, transportation services, medical assistance).

Community care coordination embraces a holistic approach to addressing the physical, social, and behavioral determinants of health. Collectively, these are integral to health care interventions needed to achieve personalized care and improved outcomes.

Tenets of the Pathways Model

Many of the tenets of the Pathways Model align closely with ecological models of health and community development. The Pathways Model embraces individual and community engagement, empowerment, collaboration, equity, and sustainability. These tenets are fundamental both to health improvement activities and to community development efforts.

The following components are the foundation of the Pathways Model.

  • Core pathways – measurement tools to define the problem to be addressed (health or social issue), the desired measurable outcome, and the key intervention steps to achieve the outcome
  • Community HUB – a regional point of registry and outcome tracking that networks health care providers, social service agencies, and health care payers that implement these Pathways
  • Pathway payments – payment for care coordination that is based on outcomes instead of activities