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Community
Care Hub

The Illinois Pathways to Health Initiative, owned and operated by AgeOptions, serves as a statewide network hub, offering a one-stop shop for social care and evidence-based health promotion programs for residents throughout the state of Illinois.
 
Guided by national models from CMS, CDC, and ACL, our Hub streamlines referrals, contracting, program delivery, and reporting to improve measurable health outcomes statewide.

Red-haired woman smiling at a table with two other people.

What We Are

What is a Community Care Hub

A Community Care Hub is a centralized entity that manages referrals, contracts, operations, and quality across a network of community-based organizations—serving as the backbone between healthcare systems and community providers.

 

As a statewide Hub, we:

  • Coordinate referrals and participant placement

  • Support delivery partners in program implementation

  • Standardize quality assurance and reporting

  • Ensure measurable, outcomes-driven performance

How the Hub Works

  1. Access & Referral: Participants enroll through healthcare referrals, community outreach, health plans, or direct registration via our website.

  2. Enrollment Coordination: AgeOptions and local delivery partners manage enrollment using standardized processes to ensure consistency statewide.

  3. Program Delivery: Certified leaders deliver evidence-based programs in community settings and virtually, maintaining program fidelity and quality.

  4. Reporting & Accountability: We collect standardized data and report outcomes to partners and funders.

Who We Partner With

  • Healthcare Providers & Health Plans: Centralized contracting, referral coordination, standardized reporting, and access to a statewide delivery network.

  • Community-Based Organizations: Expanded reach, coordinated operations, technical assistance, and sustainable funding pathways.

  • Older Adults & Caregivers: Access to evidence-based programs that support chronic disease management, falls prevention, and caregiver well-being.

Hub Infrastructure & Capabilities

  • Invoicing & Payments: Efficient processing and tracking of payments and invoices for partners.

  • Referral & Enrollment: Centralized workflows for intake, placement, and program access.

  • Data Reporting & Analysis: HIPAA-compliant data collection and outcomes reporting.

  • Contracting & Network Management: Oversight of delivery partners and compliance standards.

  • Workforce Training: Leader certification and fidelity monitoring.

  • Partner Support: Ongoing technical assistance, resources, and operational guidance.

Programs & Services

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Self-Management Programs

Support individuals managing chronic conditions such as diabetes, arthritis, and heart disease.

Older woman in mask exercises with dumbbells, seated on a chair.

Falls Prevention Programs

Workshops proven to reduce fall risk and improve mobility, balance, and confidence.

Elderly woman wearing white mask, holding papers, listening attentively indoors.

Caregiver Support Programs

Assess caregiver stress and provide personalized referrals and education.

Young woman helps older woman learn to use a digital tablet.

SDOH
Screenings

Identify social and environmental factors affecting health to connect individuals to the right resources.

FY25 Performance Snapshot

Program
Reach

  • 128 workshops delivered

  • 1,689 participants served

  • Programs offered in English, Spanish, Chinese, Hindi & Korean

Health
Outcomes

  • 81% reported improved self -rated health

  • 77% reported high confidence managing chronic conditions

Satisfaction & Quality

  • 92% program satisfaction (Self-Management) 

  • 95% program recommendation (Falls Prevention)

Our Statewide Network

Our statewide network combines infrastructure with local expertise:
​

  • 26 Community-Based Organizations

  • All 24 Care Coordination Units 

  • All 13 Area Agencies on Aging

  • Health systems, public health departments, and community partners across Illinois 

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Partnership Opportunities

If you're a healthcare plan, community organization, or interested partner, we welcome you to collaborate with us. Whether you're looking to add an evidence-based program or product to our Community Care Hub, or want to help expand our collective impact, contact us to explore partnership opportunities.​

Contact:
Rob Mapes
VP of Health Collaborations & Innovations.​
Email: robert.mapes@ageoptions.org

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