The Pathways Community HUB is a nationally certified approach that helps communities work together to support their vulnerable populations in a financially sustainable model. Local community health workers work closely with families to connect to social and medical services to remove barriers to health.

No, Hospitals, Clinical Integrated Networks, payers, healthcare systems, and statewide organizations CANNOT be the PCH entity.

CSH, CHI, and DH can participate as a Community Advisory Council member, Care Coordination Agency (CCA) and/or funder for the PCH.

The goal of the PCH is to construct a community solution to address the social determinants of health and link individuals to community resources. Community based care coordination agencies (CCAs) employ community health workers (CHWs) to reach out to those at greatest risk of poor health outcomes. The PCH provides standardization and infrastructure for the CHWs to link and track an individual’s risks through to a measurable outcome.

Once a person is identified and a standardized assessment of risk factors is completed, a specific “Pathway” is assigned for each of the individual’s modifiable risk factors. An individual may have multiple Pathways assigned simultaneously. Completion of the Pathway indicates that the person has obtained an evidence-based intervention to address the risk factor. The outcomes are then reported and beneficiaries pay for the coordination of services.

Many health interventions are limited in their capacity to account for the influence of social factors (such as low income, employment insecurity, low educational attainment, and poor living conditions) or behavioral practices. The mission of the PCH model is to work across sectors within a community to reach at-risk individuals and connect them to the evidence-based interventions and services that are necessary for positive outcomes.

The current siloes and fragmented approaches to care coordination that exist in service areas often result in duplication of services, ineffective interventions, and uncoordinated care. The PCH provides centralized processes, systems, and resources to allow accountable tracking of those being served, and a method to tie payments to outcomes. The outcomes-based payment methodology is a critical part of the PCH approach.

The PCH provides a centralized set of processes, systems, and a billing mechanism that enable communities to track individuals being served and provides a way to collect the data for outcome measurement and payment. By tracking referrals made and accomplished, the PCH has the ability to evaluate community capacity and advocate for additional resources for the community.

The PCH also provides standardized training to the community health workers to ensure quality of services as well as contracting and billing with community care coordination organizations and funding partners (government agencies, health plans, hospitals, and others). Finally, the PCH provides the technology platform to track the outcomes of the Pathways and the work the CHWs complete.

The Pathways Community HUB partners with local community-based care coordination agencies (CCAs). A PCH cannot employ CHWs or community-based care coordinators and must contract with organizations that can employ CHWs. A certified PCH must remain neutral within the Pathway community network. The PCH will establish contracts with local community-based organizations that agree to become part of the network and agrees to use standardized data collection tools and Pathways.

It is a requirement of the PCH approach that contracts with payors must be at least 50% tied to completed Pathways (resolved risks). The Pathways Community HUB Institute has developed payment codes and modifiers to track, and invoice completed Pathways. Each Pathway is assigned an outcome-based unit (OBU) based on the average amount of time it takes to complete the Pathway and the realization that not all Pathways started will be completed. The remainder of the payer contract should also compensate for work outside of Pathway completion, including requirements of the PCH around quality improvement, invoicing, and reporting.

The 21 Pathways represent individually modifiable risk factors that can be impacted through community-based care coordination. PCHI has established the Risk Reduction Research Network (RRRN) and partners with researchers studying the impact of the PCH approach. The Pathways directly connect with the risk factors and are used as a tool to measure risk mitigation. Pathways have been used in care coordination work since 2000 and have been updated to reflect improvements in our ability to track individually modifiable risk factors.

Contracted care coordination agencies (CCAs) become an integral part of the PCH network. Written contracts are developed between the PCH and the CCA. There are specific requirements that the CCA must meet through the PCH certification requirements. For example, the CCA must agree to use the PCHI data collection tools and Pathways, employ at least a .5 FTE community health worker dedicated to working with the PCH, and agree to the outcome-based payment methodology. The PCH does not contract directly with direct service providers or referral partners.

The Pathways Community HUB approach can fit it well with other care coordination efforts. It is meant to streamline and coordinate existing community-based care coordination efforts that already exist in a community or region.

The majority of Pathways Community HUBs begin with financial support from foundations or grants. PCHI advises that a new PCH obtain 2 years of funding before implementing the model. The cost depends on the size and scope of the PCH. It is best to start small and expand the Pathways Community HUB over time. For example, many PCHs start with one priority population or one targeted geographic area and expand to more at-risk individuals or a larger service area after gaining initial experience with the approach. Costs are determined by many factors: which organization takes on the PCH role (existing or new); staff for the PCH; technology solution; training needed for community health workers and their supervisors; and legal expense.

A PCH becomes certified by meeting the five steps to implementation:

Community Engagement and Planning

Fulfill Prerequisites for HUB Certification Eligibility

Fulfill PCH Certification Program's Standards

Obtain Certification through PCH Institute

Stay Certified

Please click here for additional information and to see the prerequisites and standards.

Please contact CommonSpirit Health Community Health Department at Brian.Li@CommonSpirit.org for more information.

Training for CHWs is very important. A certified Pathways Community HUB must show that their CHWs and supervisors meet minimum training requirements to participate in the network. Even if a community has a CHW training program, CHWs need to learn how to use the data collection tools and 21 Standard Pathways with their outreach. One of the key functions of the PCH is to reach out to the larger community and provide information and education on how the PCH operates. Most PCHs do have marketing strategies in place to reach community members, providers, and referral partners.