The Pathways Community HUB (PCH) model helps communities work together to support their vulnerable populations. Local community health workers work closely with families to connect to social and medical services to remove barriers to health. The PCH model has more than 20 years of experience and research in efforts to engage communities in finding those at greatest risk.

The PCH model has five goals:

1. Increase access to and impact of community services using standardized evidence-based care coordination practices that address social determinants of health needs.
2. Realign financial incentives to achieve sustainability for care coordination to vulnerable individuals with a fee-for-performance model based on end-to-end outcomes (not just services).
3. Provide standardized metrics for each referral / Pathway, to improve the ability to track, measure, and calculate cost savings on a community’s population health outcomes.
4. Decrease duplication and unnecessary work by centralizing and democratizing community care coordination.
5. Establish an intermediary PCH entity that will contract with small care coordination agencies who have limited resources and are unable to establish a sustainability model to address health inequities.

PCH will allow our health entities to assist members beyond their immediate medical needs by addressing the upstream factors and vulnerabilities that contribute to an individual’s overall health. By contracting with local community-based care coordination agencies, PCH will provide community members with intensive care coordination with the aim to mitigate risks for an individual's medical, social, and behavioral health outcomes. Once the outcomes are documented, for example, a person is housed for 30 days, PCH bills the funders and payers for the care coordination services the community health worker completes and the individual’s risks mitigated.