Illinois Pathways to Health – Community Care Hub

| Our Approach to Community Care

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.

Illinois Pathways to Health is at the forefront of the Community Care Hub movement—a national model supported by the Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Administration for Community Living (ACL). These hubs combine healthcare with social support services to ensure better overall health outcomes.

As a statewide hub, we offer a structured care system that streamlines referrals and ensures ongoing support for partners, clients, and healthcare organizations across Illinois.

Community Care Hub System Diagram

Our Community Care Hub Capabilities

We specialize in the infrastructure and support services that connect individuals and communities to programs improving their health and well‑being. This includes:

  • 🔷 Invoicing & Payments – Processing and tracking payments.
  • 🔷 Contracting & Network Management – Managing contract negotiations & legal support.
  • 🔷 Marketing & Outreach – Equipping partners with program & marketing materials.
  • 🔷 Recruitment – Expanding our reach by recruiting new participants.
  • 🔷 Workforce Training – Ensuring service quality & program fidelity.
  • 🔷 Referral & Enrollment – Screening & securing client referrals.
  • 🔷 Data Reporting & Analysis – Collecting and submitting data to track program effectiveness and compliance.
  • 🔷 Partner Engagement & Support – Providing data systems and support to help partners manage their workshops.
  • 🔷 HIPAA Compliance Training – Protecting participant privacy and security.

What Sets Us Apart

Through innovation, collaboration, and deep expertise, we’re transforming how communities' access and receive care:

  • 🔷 Our Mission – We innovate, partner, and advocate to improve systems and services in order to strengthen communities so people thrive as they age.
  • 🔷 National Community Care Hub Movement – Part of CMS/CDC/ACL’s National Learning Collaborative to integrate healthcare and social services. 
  • 🔷 Strong Infrastructure – Funded by USAging, ensuring continued network growth.
  • 🔷 Social Care Experts – We blend and braid resources to address health-related social needs (HRSNs), providing comprehensive solutions to overcome barriers to health.
  • 🔷 Leaders in Innovation – A partner of the Health Equity Learning Collaborative - Partnership to Align Social Change, working to improve health equity for Illinois residents.
  • 🔷 Statewide Partnerships – We collaborate with health systems, community-based organizations, and public health entities to expand impact.
  • 🔷 Sustainability Focused – Our expert grant-writing team secures funding to support long-term program success, with future plans to implement Medicare & Medicaid billing.

Current Products Offered

SDOH

Screenings

SDOH Screenings

  • What it is: Assessments to identify social and environmental factors impacting health.
  • Why it matters: Connects individuals with food, housing, and financial support resources.
  • Who it helps: Anyone struggling with social determinants of health.

Caregiver Assessments &

Support

  • What it is: Tools to evaluate caregiver stress, needs, and available resources.
  • Why it matters: Supports family caregivers with personalized resources, reducing burnout.
  • Who it helps: Family members and friends providing care to loved ones.

Falls Prevention

Programs

  • What it is: Evidence-based workshops to reduce falls.
  • Why it matters: Preventing falls improves independence and quality of life.
  • Who it helps: Older adults at risk of falls or those who want to maintain mobility.

Self‑Management

Programs

Self-Management Programming

  • What it is: Workshops for managing chronic conditions like diabetes, heart disease, and arthritis.
  • Why it matters: Teaches strategies to improve quality of life and reduce health complications.
  • Who it helps: Individuals living with chronic conditions and their caregivers.

Our Impact

Since 2015, Illinois Pathways to Health has positively impacted the lives of over 13,000 Illinois residents through evidence-based health promotion programs. Our programs enhance self-care, improve healthcare communication, and build stronger community connections.

Our Trained Leaders & Certifications:

  • 308 trained leaders delivering high-quality, evidence-based programs
  • 665 total certifications across multiple programs, ensuring expert facilitation and participant success

Key Achievements in FY24:

  • 170+ workshops hosted in 22 counties
  • 1,735 participants, with 1,121 completing the full series
  • 79% of participants reported excellent or good health after completing a Self-Management workshop
  • 91% satisfaction with Self-Management, and 96% with Falls Prevention programs
  • 80.4 Net Promoter Score, with 80% recommending the Self-Management program

Program Outcomes:

  • Self-Management: 82% of participants reported increased confidence in managing chronic conditions (up from 78%)
  • Falls Prevention: 94% felt more comfortable increasing activity post-program, and 81% reported reduced fear of falling
  • Health Improvement: 8.85% improvement in self-reported health from the Self-Management program
  • Falls Prevention Results: 6.4% reduction in falls

Cultural Reach:

  • Our workshops are offered in Spanish, Arabic, Chinese, Hindi, and Korean, expanding access to diverse communities.
Year in Review 2024

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. Our trusted partners and supporters include:

Community-Based Organizations

  • Arab American Family Services
  • Community Health Partner of Illinois
  • Covenant Transitions
  • Door Township (SOAR@door)
  • DuPage Health Coalition
  • Family Service Senior Resource Center
  • Hanul Family Alliance
  • Metropolitan Asian Family Services
  • National Kidney Foundation of Illinois
  • New Hope Christian Center
  • Oswegoland Senior & Community Center
  • Real Foods Collective
  • Sisters Working It Out
  • 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
  • Warner Hospital

Care Coordination & Aging Support

  • AgeGuide
  • AgeLinc
  • Catholic Charities DOJ
  • Catholic Charities Lake County
  • Central Illinois AAA
  • Community Care Systems, Inc.
  • CRIS Healthy Aging
  • East Central Illinois Area Agency on Aging
  • Oak Park Township
  • 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