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Winona Family Y, 902 Parks Avenue, Winona, MN | 507.474.9825

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Winona Community HUB

Working together to ensure all Winona families have access to the resources they need to live their best lives

The HUB is an evidence-based model of community care coordination that focuses on addressing social determinants 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:

*Winona County Residents and

*Someone in the household has screened as food insecure OR

*Someone in the household has been diagnosed or self-reported mental health concerns OR

*Is experiencing homelessness.

Visit the Center for Disease Control (CDC) to learn more about social determinants of health (SDOH).

The Three Core Elements of the Winona Community HUB model:

FIND

magnifying lens over teamwork series with leader

Identify individuals/families at greatest risk and provide a comprehensive assessment of health, social, and behavioral health risk factors.

TREAT

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).

MEASURE

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 one different pathways:

• Adult Education • Immunization Referral • Mental Health
• Developmental Referral • Learning • Oral Health
• Employment • Medical Home • Postpartum
• Family Planning • Medical Referral • Pregnancy
• Food Security • Medication Adherence • Social Service Referral
• Healthcare Coverage • Medication Reconciliation • Substance Use
• Housing • Medication Screening • Transportation

Winona Community HUB Process:

The HUB Process Explained
  • A family meeting referral criteria 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, 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 21 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.

Videos

Pathways Community HUB 101

Winona Community HUB named a Trailblazer

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 is to connect people in Winona to the resources they need to live their best lives. Active WWC partners include:

*Advocacy Center of Winona

*Bluff Country Co-op

*Catholic Charities of Southern Minnesota

*Engage Winona

*Family & Children’s Center

*Habitat for Humanity

*Hiawatha Valley Mental Health Center

*Miller Mentoring

*Project FINE

*Winona Area Public Schools

*Winona County

*Winona Health

*Winona Volunteer Services

*Winona Family YMCA

Winona Community HUB Goals:

1. To ensure the complex needs of Winona families experiencing barriers to various services are systematically identified, assessed and treated through evidence-based interventions to improve their outcomes;

2. To ensure seamless, effective, and unduplicated care is provided by service agencies;

3. Thereby improving financial and health security for Winonan families in need.

Referral Agencies:

Advocacy Center of Winona

Catholic Charities of Southern Minnesota

Family & Children’s Center

Habitat for Humanity

Hiawatha Valley Mental Health Center

Miller Mentoring

Winona Area Public Schools

Winona County

Winona Health

Winona Volunteer Services

Winona Family YMCA

Funded by:

Braided funding, including grants and outcomes-based payments from health care payers

Contact:
For more information on the Winona Community HUB or to learn more about how to make a referral, please contact:

Rachel Stoll
Community Wellbeing Coordinator & Winona Community HUB Manager
Live Well Winona
507.457.4400
rachel.stoll@livewellwinona.org

Vanessa Southworth
Community Wellbeing Director
Live Well Winona
507.457.8530
vanessa.southworth@livewellwinona.org

 

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  • About Us
    • Contact Us
    • Mission, Vision, Values
    • Leadership
    • Our Story
    • Annual Report
    • Donate
  • Facts & Wellness
    • Community Health Needs Assessment
    • Risk Factors & Related Illnesses
      • Obesity
      • Diabetes
      • Smoking
      • Alcohol
      • Physical Inactivity
      • Access to Healthy Foods
      • Mental Health
      • Social Support
      • High School Graduation
      • Unemployment
    • Dimensions of Wellness
      • Intellectual Articles
      • Spiritual Articles
      • Social Articles
      • Physical Articles
      • Occupational Articles
  • Resources
    • Resource Directory
    • Health Assessments & Calculators
    • Recipes
    • Winona Community HUB
  • Programs & Events
    • Alliance for Substance Abuse Prevention
    • GR8 Kids
    • Winona Community HUB
    • Community Calendar
    • Community Trainings
  • News
    • Press Room
    • Newsletter Archive
  • Volunteer Hub