How it Works


Today, vulnerable individuals are connected to service providers who address SDoH through passive referrals with brochures/pamphlets or electronic referrals. These referrals, while well-intentioned, are reactive, lack integration, and are not standardized, often leaving the individual to navigate and address any additional barriers (transportation, child care, etc.) leading to a low rate of success.

At the health system level, there are many gaps with the aforementioned situation today:

  • Inability to track and monitor outcomes for social needs across multiple programs or health entities
  • Retention of CHWs due to intermittent grant funding
  • Financial incentives are misaligned between health plans, health systems, and other beneficiaries
  • No standardized process and procedures for social needs assessment and referrals data
  • Duplicative efforts and lack of shared care plan between health entities

The Pathways Community HUB model is structured to address these gaps.


Pathway Community HUB entity: The central Pathway Community HUB is a neutral organization that provides infrastructure for community-based care coordination and is responsible for building the network and developing contracts with participating agencies (funders, care coordination agencies, and the technology platform). The PCH entity does not employ care coordinators but is responsible for quality measurement, tracking services to avoid duplication, data collection and reporting, and billing for outcomes. Hospitals, Clinical Integrated Networks, payers, healthcare systems, and statewide organizations CANNOT be the Pathways Community HUB entity.

Care Coordination Agencies (CCAs): Organizations such as social service agencies, health clinics, and mental health agencies that partner with the PCH entity to employ CHWs who work one on one with at-risk or rising risk individuals.

Community Health Workers: The CHWs serve as frontline public health workers who have a close understanding of the communities they serve. This trusting relationship enables the CHWs to serve as a link between healthcare entities, social services, and the community to increase access to services and improve the quality and cultural linkages of service providers. The PCH infrastructure provides tools and strategies that will ensure at-risk and rising risk individuals in a community are served in a timely and coordinated manner by utilizing CHWs to coordinate care. CHWs are employed by Care Coordination Agencies.

Standard Pathways: The most common barriers to health outcomes, such as employment, housing, and transportation, are categorized into 21 standardized Pathways. CHWs partner with PCH participants to break down these barriers and complete the Pathways that align most with the individual’s situation. An information technology platform used by the CHWs to show completed Pathways which leads to payment of coordination services. Pathways and reimbursement rates are agreed upon between the funder and the PCH during the initial set-up of the PCH. See below for the 21 Pathways.

Outcome-Based Model: The model’s major difference to other social determinant models is the financial framework that aligns cost savings from beneficiaries to those coordinating care. Payers and funders contract with the PCH to pay for completion of pathways for PCH participants. This outcomes-based funding structure ensures financial sustainability of the PCH model and is directly linked to better health outcomes for vulnerable community members. Funders include, but are not limited to, health plans including managed care plans, health care providers, foundations, and government agencies.

Certification: The Pathways Community HUB Institute (PCHI) oversees the certification of community PCHs to ensure that PCHs meet established standards and requirements. This process maintains the fidelity of the evidence-based PCH model which is key to building trust with community partners and funders.

The Pathway Community HUB’s ability to standardize and sustain CHWs to address the social needs of a community in an equitable fashion aligns with CommonSpirit Health’s mission to improve the health of the people we serve, especially those who are vulnerable, while advancing social justice for all. PCHs provide community care coordination across the continuum of health in target populations such as low income, high utilizers of crisis health services, lack access and resources to coordinated services, lack of health education and individuals with one or more chronic physical or behavioral health conditions.

CSH chose the Pathways Community HUB (PCH) model because of it’s integrated approach to reaching at-risk individuals and connecting them to the evidence-based interventions and services that are necessary for positive outcomes.

21 Standard Pathways:

Standard Pathways

These Pathways have specific outcomes that are pre-set by the Pathways Community Hub Institute.


Housing Pathway Outcome: Household member (s) have maintained safe and stable housing for 30 days from move-in date.

Mental Health Pathway Outcome: Confirm participant has kept 3 scheduled mental health appointments.

Substance Use Pathway Outcome: Participant kept appointments and treatment related to substance use for 30 days.

To learn more about the outcomes for each of the Pathways, click here.

To learn more about how it works, please review the Pathways Community HUB Playbook which goes further into the mechanics of the model.

© Copyright 2021 CommonSpirit Health. All rights reserved. The information contained on this site is both proprietary and confidential.

Copying, dissemination, or distribution of such information outside of CommonSpirit is strictly prohibited.