The Constellation Community Care Hub standardizes utilization of community-clinical linkages for better health outcomes

We know that social factors like access to healthy food, safe housing and stable employment have a major impact on our health. We also know that organizations across our communities are encountering clients with health-related social needs that must be addressed to improve outcomes.

So, what would it look like to build community-clinical connections that would get patients the resources they need to truly reduce health disparities?

The Constellation Community Hub (Hub) aims to be that connection – creating effective community-clinical linkages that prioritize equitable care delivery. The Hub is a community of care hub – a centralized, bi-directional, closed-loop referral hub that allows providers to refer patients to meaningful programs and community resources. This collaborative space will unite clinical care delivery and social care to create an authentic, engaging link between community and health care.

Staffed by Community Health Workers (CHW), the Hub will engage referred clients to understand their needs and make appropriate referrals to address them to make a difference in their care – and their outcomes – through a wide range of community-based organizations and nonprofits, including faith-based organizations.

Photo of female doctor with patient

How Does The Hub Work?

Providers refer patients to the Constellation Community Hub to facilitate community-clinical linkages to address social determinant needs impacting patient health outcomes. Our CHW Navigators work with the patients to develop a whole-person plan of care and coordinate services on their behalf that address their health-related social needs.

Why Get Involved?

Joining the Constellation Community Hub creates a triple win. Providers gain access to the resources they need to better support patients. Community-based organizations get a referral pipeline, managed by experienced Navigators. Community members gain equitable access to the resources that will improve their lives – and their health.

For Community-Based Organizations

The Hub will foster collaboration and a robust referral pipeline to support organizations that are making a direct impact on health outcomes in your community.

The Hub will:

  • Create a centralized network of resources
  • Efficiently match up your organization’s expertise with community needs
  • Create a targeted referral pipeline of clients that directly align with your mission and programs
  • Make a direct impact on the social determinant needs of your community, creating better health care outcomes

For Providers

The Hub offers a central, trusted point of contact to help providers address the social determinants of health that are impacting their patients’ health issues.

The Hub will:

  • Meet whole-patient needs through a coordinated system of care
  • Address equity and access issues that impact health outcomes
  • Manage the referral process to multiple organizations that address a range of social needs
  • Relieve the strain on clinical staff to navigate referrals and outcome feedback
  • Continuously review and update available resources to maintain a strong and accurate centralized resource