Specifications include, but are not limited to: Goal 1: Serve as a Pathway Community HUB (PCH) for Delaware. 1.1 Serve as a neutral entity in the community. To ensure neutrality the PCH may not employ its own Community Health Workers (CHW). 1.2 The PCH must be based in Delaware. 1.3 Identify individuals to serve on the Community Advisory Board. Members of the board should reflect the communities made up of members reflect the communities the PCH serves. Receive technical Assistance from the Pathways Community HUB Institute to ensure that the PCH utilizes best practices and evidence-based strategies. 1.4 Identify key stakeholders such as potential payers and the Delaware Community Health Worker Association. 1.5 Engage stakeholders and the community in discussions about the PCH model. 1.6 Conduct or utilize existing community needs assessments to implement the PCH model. 1.7 Develop infrastructure, hire and train appropriate staff, and operate with a collaborative intersectional approach. 1.8 Hold discussions with the Delaware Division of Public Health and the Community Health Worker Association to determine if the PCH should apply for and maintain certification. Goal 2: Develop the infrastructure to support the implementation of a Community Hub model in Delaware. 2.1 Ensure the statewide network of Community Health Workers (CHW) utilize CHW tools to include • Evaluation tools o Demographic Profile/ Initial Checklist o Visit Form o Progress Form o Care plan requirements for pathways o Standards for a completed pathway and the discharge of clients once identified needs have been addressed. 2.2 Implement statewide data collection tool for tracking and reporting to be utilized by community-based Community Health Workers. 2.3 The PCH will maintain a repository of information collected from evidencebased collection tools. The PCH should ensure information collected is: • Centralized • Easily cross referenced to minimize duplication of clients • Reviewed routinely to monitor the progress of individual clients in real time • Compiled into monthly, quarterly, and/or annual reports • Evaluated to inform trainings conducted by the PCH and the Community Health Worker Association • Utilized to inform standing monthly meetings with Community Health Workers • Utilized to provides Community Health Workers with real time feedback 2.4 Conduct training to ensure that community based CHW and other stakeholders are able to effectively utilize the Community Hub data collection tool and are trained on the Community Hub Pathways Model. 2.5 Perform ongoing quality assurance and improvement efforts.
