Early Childhood Wellness Hub

Community Driven

  • Community members and Early Childhood Development (ECD) Stakeholders develop their shared goals and indicators of success

Network of Local Service Providers

  • Data Sharing Agreements
  • Shared Intake Process
  • Shared Referral Process

Care Navigation

  • Develop Local Pathways to Care
  • Identification of Families in Need
  • Connection to Services
  • Service Navigation (by utilizing Community Health Workers)
  • Identification of system Barriers and Gaps in Services

Community Owned Transformation

  • Local Community and ECD Stakeholder developed strategies for Policy, System and Environmental Change Interventions, Tactics and Action
  • Focus on Family Engagement and Community Mobilization to enhance community resiliency

The Alhambra Family Resource Center Pilot Project:

The Early Childhood Wellness Hub Model

The process of identifying at-risk individuals and connecting them to the health and social services they need is often referred to as care coordination. Care coordination is a broad term that is often thought of as a process that occurs within the health care system. Community hub models specifically addresses community care coordination, which can be defined as the coordination of services beyond the “walls” of the health care system. Care coordination seeks to meet a variety of needs.

These needs may include help with housing, transportation, employment, and education in addition to accessing health care services. Care coordination occurs within many different and most often isolated domains of the health, behavioral health, and social service system. The current business model for delivering care coordination services remains inadequate. For example, it is most common for care coordination services to focus on “activities” that may or may not produce positive outcomes. And while more than one organization may provide care coordination services within a given geographic area, generally little or no collaboration occurs across these programs. Individuals fall through the cracks and efforts are duplicated. A high-risk pregnant woman may have multiple care coordinators who do not interact with each other and another high-risk person may have no care coordinator.

Three fundamental business model problems exist with the current approach to care coordination— lack of meaningful work products, duplication of effort, and failure to focus on those most at risk. The fragmentation and duplication of services and poor outcomes resulting from poor care coordination increase health care costs.

Community Hub Models

The models researched (The Magnolia Project, Community Health Access Project, Families to Family, and Help Me Grow) all showed common goals, summarized below:

  1. Develop a needs assessment that considers both quantitative data and lived experience
  2. Build a Network of Service Providers
  3. Share Data
  4. Establish Uniform Referral Systems
  5. Identify Families in Need
  6. Connect Families to Services
  7. Enhance Community Engagement

The models further discuss various programmatic elements that must be considered as the hub is designed.

  1. Infrastructure
  2. Governance
  3. Data-Based Decision Making
  4. Data Sharing Agreements
  5. Patient Navigation
  6. Establishing Pathways to Care
  7. Quality Improvement
    •  Referrals
    • Duplication of Services
    • Surveillance
    • Quality of Services
    • Availability of Services

Our Result Statement

Children (0-8) and their families in Alhambra will have access to and receive the services needed to lead a healthy and productive life.


Children 0-8 in Alhambra Elementary School District with special attention to the uninsured, under insured, refugee and undocumented populations.

In Collaboration with