Community Care Hub
The Illinois Pathways to Health Initiative, operated by AgeOptions, serves as a statewide network hub, offering a one-stop shop for social care and evidence-based health promotion programs. As a Community Care Hub, we combine healthcare with social support services to improve health outcomes, guided by national models from CMS, CDC, and ACL. Our integrated approach streamlines referrals and ensures ongoing support for partners, clients, and healthcare organizations across Illinois.
Why the Hub Matters
We deliver coordinated, evidence-based programs that connect participants to the right services and address social and environmental factors affecting health.
Better Access
Coordinated referrals reduce barriers to care and connect participants to needed supports.
Stronger Partnerships
Aligning healthcare systems and community organizations for high-quality, efficient service delivery.
Equity & Impact
Programs are inclusive, culturally responsive, and outcomes are tracked to ensure measurable improvements.
How the Hub Works
We provide partners with infrastructure and support so every participant receives timely, effective services.
Deliver Workshops
Evidence-based programs for chronic disease, falls prevention, and caregiver support.
Connect to Social Supports
Screen for social determinants of health and link participants to resources.
Manage Referrals & Compliance
Streamline enrollment, invoicing, and HIPAA-compliant reporting.
Track outcomes
Measure program effectiveness and participant progress.
Who We Support
Our hub connects a range of partners and participants across Illinois:
Healthcare Plans
Healthcare systems connecting patients to community-based programs.
Community Organizations
Local providers delivering evidence-based workshops seeking visibility and partnerships.
Care Coordinators
Social workers needing reliable, trackable community connections.
Participants & Caregivers
Individuals accessing programs to maintain independence, health, and well-being.
Programs & Products Available
Falls Prevention Programs
Evidence-based workshops proven to reduce fall risk and improve mobility, balance, and confidence.
Self-Management Programs
Help individuals manage chronic conditions such as diabetes, arthritis, and heart disease.
SDOH
Screenings
Identify social and environmental factors affecting health to connect individuals to the right resources.
Caregiver Assessments & Support
Assess caregiver stress and guide personalized referrals and education.
Our Hub Capabilities
We connect individuals and communities to programs that enhance health and well-being.
Operations & Instructure
Invoicing & Payments
Efficient processing and tracking program payments.
Contracting & Network Management
Managing contract negotiations & legal support.
HIPAA Compliance Training
Protecting participant privacy and security.
Access & Referrals
Referral & Enrollment
Screening & securing client referrals.
Data Reporting & Analysis
Tracking outcomes and compliance.
Marketing & Outreach
Equipping partners with program & marketing materials.
Network & Program Delivery
Workforce Training
Ensuring service quality & program fidelity.
Partner Support
Providing data systems and assistance for workshop management.
Recruitment
Expanding our reach by enrolling new participants.
What Sets us Apart
Part of the National Community Care Hub movement
Strong statewide infrastructure
Expert in social care & HRSNs
Innovative, equity-focused partnerships
Sustainable, long-term impact
FY25 Outcomes & Impact
During FY25, Illinois Pathways to Health delivered evidence-based programs statewide, achieving measurable outcomes in participation, health improvement, and satisfaction.
For full FY25 statistics, download or [FY25 IL Pathways Program Report PDF].
Program Delivery
128
Workshops Delivered
16
Counties Served
954
Completers
Health Outcomes
81%
Reported positive self-reported health
77%
Reported high confidence in managing chronic conditions
Satisfaction & Quality
92% satisfaction
Self-Management programs
95% satisfaction
Falls Prevention programs
Access & Equity
Programs offered in Spanish, Chinese, Hindi, and Korean
Delivery across urban, suburban, and rural areas
Our Collaborative Network
We are proud to collaborate with 26 community-based organizations (CBOs), all 24 Care Coordination Units (through CCA), and all 13 Area Agencies on Aging (AAAs) in Illinois.
Community-Based Organizations
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Community Health Partner of Illinois
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Covenant Transitions
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Door Township (SOAR@door)
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DuPage Health Coalition
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Family Service Senior Resource Center
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Hanul Family Alliance
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Illinois Migrant Council
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Metropolitan Asian Family Services
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National Kidney Foundation of Illinois
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New Hope Christian Center
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Oak Park Township
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Oswegoland Senior & Community Center
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Real Foods Collective
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Sisters Working It Out
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The Oasis Institute
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Village of Schiller Park
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Wellness House
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White Crane Wellness Center
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Williamson County Programs on Aging
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Xilin Association
Health Systems & Public Health Partners
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Advocate Sherman Hospital
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Alivio Medical Center
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McHenry County Dept. of Health
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Rush Health and Aging
Care Coordination & Aging Support
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Catholic Charities DOJ
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Catholic Charities Lake County
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Community Care Systems, Inc.
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CRIS Healthy Aging
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Senior Services Associates, Inc.
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Senior Services of Central Illinois
Libraries & Educational Institutions
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Lansing Public Library
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Richton Park Public Library
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University of Illinois
Interested in Joining Our Network?
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