Working together to address food insecurity in high-risk populations
The HUB is an evidence-based model of community care coordination that focuses on addressing social determinant of health (SDOH) risk factors in food insecure or other high-risk individuals. The Winona Community HUB provides the structure to ensure that Winona’s most vulnerable families’ complex needs are addressed in an equitable, unduplicated and meaningful way. The target population for referrals are households must include minors that are 17 years old and under, are Minnesota residents and reside within 25 miles of the city of Winona. In addition, requirements include being screened as food insecure and are either uninsured/private pay, or Minnesota Medicaid.
Visit the Center for Disease Control (CDC) to learn more about social determinant of health (SDOH).
The Three Core Elements of the Winona Community HUB model:
Identify individuals/families at greatest risk and provide a comprehensive assessment of health, social, and behavioral health risk factors.
Ensure each identified risk factor is assigned to a specific pathway ensuring that risk factors are addressed with an evidence-based or best practice intervention (e.g., parenting education, housing, food, clothing).
Completion of each pathway confirms that risk factors have been successfully addressed. Measurement includes other outcomes that involve multiple risk factors (e.g., improvement in chronic disease, reduction in emergency department visits, stable housing, and employment).
A pathway is an evidence-based intervention or service that addresses a specific SDOH risk factor to improve their outcomes. In the HUB model, there are twenty different pathways that include:
|• Adult Education||• Health Insurance||• Medication Assessment|
|• Behavioral Health||• Housing||• Medication Management|
|• Developmental Referral||• Immunization Referral||• Postpartum|
|• Developmental Screening||• Immunization Screening||• Pregnancy|
|• Education (General)||• Lead||• Smoking Cessation|
|• Employment||• Medical Home||• Social Service Referral|
|• Family Planning||• Medical Referral|
Winona Community HUB Process:
- The HUB Process Explained
- A family experiencing food insecurity is identified at a community referral partner agency.
- The Agency recommends that the family receive community-based care coordination services, and the family agrees.
- The family is referred into the HUB through a web-based portal and a community-based care coordinator is assigned from a participating Community Care Coordination Partner.
- An appointment is arranged, and the community-based care coordinator visits the home of the at-risk family.
- During the first home visit, a consent is obtained and a comprehensive evaluation of risk factors is initiated for all household members that want to participate.
- For each risk factor identified, one of 20 different Pathways will be initiated (house instability, lack of employment, etc.).
- The community-based care coordinator will support the family in resolving each Pathway to an outcome across relevant service-providing agencies. There is no time limit on how long the family may receive this support.
- Progress is tracked in a secure documentation tool, and the community-based care coordinator will update relevant agencies as needed.
Winona Wellbeing Collaborative (WWC)
The Winona Wellbeing Collaborative (WWC) serves as the governance body of the Winona Community HUB (HUB), a community-based care coordination program supported by collaborating organizations. The HUB addresses the complex needs of families experiencing financial and food insecurity to ensure they have the resources they need to achieve the best health outcomes possible. The mission of the Winona Wellbeing Collaborative connects people in Winona to resources they need to live their best lives. Active WWC partners include: Winona Health, Winona County Human Services, Winona Volunteer Services (Winona’s food and emergency services nonprofit), Project FINE (Winona’s immigrant services non-profit), Winona Area Public Schools, Live Well Winona, and Bluff Country Co-op. There are further community partners in-waiting and ready to engage as WWC’s reach grows.