The Pathways Community HUB Institute® Model

Formation:
Founded from Drs. Mark & Sara Redding because of their positive work with community health
workers first in Alaska then in Baltimore, Maryland. While in Alaska they developed a program
utilizing community health workers CHWs then utilized the program they developed in
Baltimore Maryland using Pathways they were creating to work on reducing low birth weight in
Alaska.
Founded on the simple idea of health equity
Description:
“A Pathways Community HUB (PCH) is an organized, outcome focused, pay for performance
network of community-based organizations that hire and train community health workers
(CHWs) to reach out to those at greatest risk, identify risk factors and barriers, and assure
connections to medical, social, and behavioral health services. PCHI® Model Certification
outlines 10 Prerequisites and 18 Standards to guide communities as they build a Pathways
Community HUB to fidelity. A nationally certified PCH improves health, reduces costs, and
promotes health equity.” ~ https://www.pchi-hub.org/our-model
Commitments:
Provides communities a sustainable and transformational care coordination network
Ensures neutrality, transparency, and accountability to the community
Provides tools/training for CHWs to identify risk factors and develop a plan to remove those
risks
Provides infrastructure for tracking risk factors throughout services
Provides structure for a strong network of services to improve systems of care, remove barriers
to service delivery, reduces duplication of systems while enhancing systems at the same time.
Links positive outcomes with payment
Only 1 PCH per community/region to remove silos and eliminate duplication of services.
PCH does not employ CHWs, PCH contracts with existing organizations, Care Coordination
Agencies (CCAs); CCA’s hire CHWs and their supervisors
Roles:
CHWs were the inspiration for this model
CHWs from their own communities regularly meet w/clients/build rapport/relationship, assess
needs/risks based on our 21 Pathways
CHWs work with clients using Pathways Learning Modules to identify risks and needs to
develop a plan of care with the ultimate goal of help clients learn how they can improve their
health.
CHWs have the ability to work with under resourced, at-risk clients in a unique way, engaging
with them and connecting with them to assist those that may otherwise likely be overlooked
Implementation:
Pathways Agency (PA)
A PA adopts the PCHI Model, utilizing the standard data collection tools and 21 Pathways. PA
hires supervisors and CHWs to work with clients on Pathways. PA commits to future of Certified
Pathways Community HUB via collaboration with community partners.

Once a Pathways Community HUB is operating in the PA’s service area and has applied for
certification, the Pathways Agency certification will lapse within six months.

Pathways

Pathways are used to identify and monitor risk factors to work towards measurable outcomes that
would improve quality of life for the client. If the outcome is met, the pathway is closed; if it is
unable to be met, it is documented incomplete. Payment is directly related to the Pathways
Community HUB with 50% of payments being related to closed Pathways
.
Adult Education Housing Pregnancy
Medical
Developmental Immunization Reconciliation Social Service
Referral Referral Referral
Medical
Employment Learning Screening Substance Use

Family Planning Medical Home Mental Health Transportation

Food Security Medical Referral Oral Health

Health Coverage Medical Postpartum

Data Collection:
CHWs utilize an effective tool, the PCHI Model Visit Form to collect data from the client. To
avoid the impression of data gathering, it utilizes a conversational approach with the client using
the 21 Pathways to establish risk.
PCHI utilizes a Quality Benchmark Report (QBR) to collect data and report quarterly to
Certified Pathways Community HUBs and Pathways Agencies. These reports are a requirement
for quality assurance and performance measurement.
All in the PCH Network must use the PCHI Model for standardized data collection.
Data that is gathered by the PCH network is presented to the Community Advisory Council for
review and action.
Reimbursement:
Financial sustainability is vital for community-based organizations and the community health
worker workforce. With the PCHI Model, Pathways Community HUBs and Pathways Agencies
can be reimbursed as they complete Pathways with their residents.
Once clients’ needs are addressed and upon completion of Pathways, PCHs then bill Medicaid or
other payor sources
Payment is linked directly to outcomes
Outcomes:
The PCHI Model is an outcome-based unit (OBU) payment methodology. Each Standard
Pathway is assigned a billing code and outcome-based unit according to the time/complexity of
the pathway.
Currently in 35 Communities
Current PCHI implementation communities using the Model is having positive outcomes
When linked to appropriate health, wellness and social services client will experience healthier,
more fulfilling life
Improvement in health, health equity and reduction in health care costs have all been results of
PCH. National Certification has provided standardization that must be followed regarding 10
prerequisites and 18 standards.