Pathways Community HUB

A CommonSpirit Health collaborative with local communities

Introducing Pathways Community HUB

Our Mission

As CommonSpirit Health, we make the healing presence of God known in our world by improving the health of the people we serve, especially those who are vulnerable, while we advance social justice for all.

To improve the health of vulnerable people we serve, CommonSpirit Health understands that health does not happen in a silo, an individual's health has many factors within medical care, social services, behavioral health, and the environment - such as housing, food, mental status, - are interdependent. CommonSpirit Health's Community Health team is committed to addressing health-related social needs sustainably, one of the initiatives that help to address these social needs is the Pathways Community HUB model.

The Pathways Community HUB (PCH) model is an evidence-based pay for outcomes model that leverages Community Health Workers (CHWs) to orchestrate care for individuals and connect them to community resources to meet their health and social needs. The model provides a centralized system to track services and tie payments to outcomes that improve the health of vulnerable and underserved populations.

CSH chose the Pathways Community HUB (PCH) model because of its integrated holistic approach to reach any individual in the community who has social needs and to connect them to the evidence-based interventions and services that are necessary for positive outcomes.

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Potential Locations

Pilot PCH Locations

  • Brazo County, TX
  • Clark County, NV
  • Omaha, NE
  • San Joaquin, CA

Pilot CCA Locations

  • Maricopa, AZ
  • Yolo, CA
  • Pierce/King, WA

Click here for updates on pilot locations.

Pathways Community HUB Goals

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.

Click on the following to learn more:

Please contact CommonSpirit Health Community Health Department at for more information.

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