The Holyoke Hub: A collaborative initiative that makes a difference, case-by-case

The best innovations are, with little doubt, the ones that elicit this collective refrain: “Why didn’t anyone think of this sooner?”  

Such is the case with the Holyoke Hub, a low-cost initiative that has been delivering a high rate of success for at-risk youth, individuals, and families since it began in April 2022. It’s modeled after programs launched in 2015 in Chelsea and Springfield, Massachusetts.  

At first glance, the Hub model may appear deceptively simple: Designate a weekly time and space for staff from city services and community agencies to talk—in a holistic manner—about specific situations that pose a high probability of harm and intersect multiple service sectors.  

The key word here being “talk,” as Hub conversations can boost both communication and collaboration among dozens of organizations—police, medical providers, public schools, Way Finders, Community Legal Aid, and YMCA, to name a few—and deliver a more effective response that any one agency could accomplish on its own. Plus, the burden of navigating resources is taken off the shoulders of those who are struggling, to be shared by staff who are well versed in how to access help. And as various staff collaborate, their own relationships strengthen. 

“Navigating that maze of resources as an individual at risk? It’s intimidating, it’s exhausting,” said Accountable Care Organization Manager Sara Pena, who began participating in the Holyoke Hub at the end of 2022—and is joined by other Way Finders’ staff, including Homelessness Prevention Services Manager Judith Cardona and Chief Program Officer Janette Vigo. “The Hub has worked out for some of our clients as a really, really good idea. There are people who I don’t think would otherwise ever have really connected to all the systems of care that they need. So seamlessly, and in a really timely fashion.” 

The virtual meetings are led by Ed Caisse of the Hampden County Sheriff’s Department and the Holyoke Safe Neighborhood Initiative. They follow an intentional format—a guided conversation with clear objectives and criteria—to prioritize the privacy of individuals. The meetings last an hour, tops, or a few minutes if there are no situations to discuss. Broadly speaking, situations may involve issues related to mental health, substance abuse, housing and other basic needs.  

“Ed leads by introducing the concept of how we operate through a series of filters,” said Pena, who joined Way Finders in April 2021 as a housing navigator. “The first thing someone will present is some very basic information about a situation or risk factors that an individual is struggling with. We don’t give out any identifying information. If everyone agrees that the criteria are being met—a high-risk likelihood of harm if there’s no intervention, and a situation that crosses over multiple service sectors—we move forward to name recognition to see if anyone at the table is servicing that individual or family.” 

At this point, a subgroup takes shape—those already involved plus any other groups that could provide appropriate services—and connects on an email chain to devise a plan. 

“A lead is also identified, it could be the person who brought up the situation or any provider who can address the highest presenting need, and then follow up will happen,” said Pena. “The next week, the group gives a brief update on any progress that’s been made.”   

A recent example of the Hub’s impact involved actions to help a youth who was facing challenges in many parts of their life—at school, at home, in the community. The plan was creative, the results were noteworthy. 

“An offer of employment was extended to the youth by a local organization, to do meaningful work with other youth. With the hope that it would increase their sense of self, by doing something positive and getting positive feedback instead of all the focus on what they weren’t doing well. A way to motivate and have that trickle into other areas of the youth’s life,” said Pena. “And there was a significant turnaround in behavior and academic performance. Taking an unconventional approach to trying to solve old problems, that’s something we’ve seen in a lot of different situations.” 

When a situation involves housing instability and meets certain health-related criteria, such as a high-risk pregnancy or a chronic health condition, the person may qualify for housing support through Way Finders’ Accountable Care Organization (ACO) partnerships. (An ACO is a group of health-care providers and insurance networks who coordinate to give high-quality care to the MassHealth/Medicaid patients they serve.)  

“There have been a few individuals who have a housing need, and while on the call Hub members can quickly verify ACO eligibility or see if they belong to a certain network,” said Pena. “And I can say, ‘Hey, yes, we can take them.’ We have gotten a few ACO referrals that way.” 

When asked to speak to the initiative’s reach, Pena’s reply highlights the Holyoke Hub’s focus on privacy and confidentiality. 

“Interestingly enough, we refer to people’s situations and not necessarily to individuals or families,” said Pena. “So a ‘situation number’ is assigned. And I think at this point, in December 2023, we have worked together on more than 70 situations.” 

Pena is most impressed by the dedication of all those involved with the Holyoke Hub: “What really stands out to me is how committed and accountable everyone is, they really believe in the work that’s being done. It’s not like your boss is going to necessarily come to you and say, ‘Hey, what’s the status here?’ The Holyoke Hub is not your boss. You’re really just there, as a part of this collective initiative, trying to make a difference. And I think that that's particularly commendable about everyone who shows up and participates.”