The Health Collaborative’s ED Care Coordination Pathway



The Health Collaborative’s ED Care Coordination Pathway serves ED super-utilizers by assigning them a community health worker who coordinates services related to patients' medical, social and behavioral health needs. Coordination services include helping a patient establish a relationship with a primary care provider, find a medical home, secure transportation to and from appointments and find stable housing.  

Partner Organizations

  • The Health Collaborative 
  • Health Care Access Now
  • 10 regional hospitals

Target Population

Individuals (primarily Medicaid enrollees, dual-eligibles and the uninsured) with 20 or more ED visits in the past 12 months

Care Team

Community-based outreach team that includes a community health worker and AmeriCorps volunteers; multidisciplinary clinical advisory team composed of physicians, a hospital case manager, a social worker and a behavioral health professional


2012 - 2014

Results/ Studies

ED visits for patients in the program for 6 months or longer decreased by 54 percent. ED-related charges declined by 62 percent.  


Private grants


Robert Wood Johnson Foundation program description

Program video

Presentation by Health Care Access Now (PDF)