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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.

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  • 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 the Hub Supports

Our hub connects a range of partners and participants across Illinois.

Healthcare Plans & Systems

Community Organizations

Care Coordinators & Social Workers

Participants & Caregivers

Programs & Products Available

Falls Prevention Programs

Evidence-based workshops proven to reduce fall risk and improve mobility, balance & confidence.

Older woman in mask exercising, holding chair during fitness class.

SDOH
Screenings
 

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

Younger woman assists smiling senior woman using a digital tablet.

Self-Management Programs

Help individuals manage chronic conditions such as diabetes, arthritis & heart disease.

Take Charge

Caregiver Assessments & Support

Access caregiver stress and guide personalized referrals & education.

Elderly woman wearing white mask, holding papers, looking up attentively.

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.

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.

Access & Referrals

  • Referral & Enrollment: Screening & securing client referrals.​

  • ​Data Reporting & Analysis: Tracking outcomes and compliance.​

  • Marketing & Outreach: Equipping partners with program & marketing materials.

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 our [FY25 IL Pathways Program Report PDF].

Program Delivery

Programs offered in Spanish, Chinese, Hindi, and Korean

 

 

​

​Delivery across urban, suburban, and rural areas

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

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

  • Community Health Partner of Illinois

  • Covenant Transitions

  • Door Township (SOAR@door)

  • DuPage Health Coalition

  • Family Service Senior Resource Center

  • Hanul Family Alliance

  • Illinois Migrant Council

  • Metropolitan Asian Family Services

  • National Kidney Foundation of Illinois

  • New Hope Christian Center

  • Oak Park Township

  • Oswegoland Senior & Community Center

  • Real Foods Collective

  • Sisters Working It Out

  • The Oasis Institute

  • Village of Schiller Park

  • Wellness House

  • White Crane Wellness Center

  • Williamson County Programs on Aging

  • Xilin Association

​

Health Systems & Public Health Partners

  • Advocate Sherman Hospital

  • Alivio Medical Center

  • McHenry County Dept. of Health

  • Rush Health and Aging

 

Care Coordination & Aging Support

  • AgeGuide

  • AgeLinc

  • Catholic Charities DOJ

  • Catholic Charities Lake County

  • Community Care Systems, Inc.

  • CRIS Healthy Aging

  • Senior Services Associates, Inc.

  • Senior Services of Central Illinois

 

Libraries & Educational Institutions

  • Lansing Public Library

  • Richton Park Public Library

  • 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

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