The Pathways Community Health Institute® (PCHI) Model helps communities build a transformative and sustainable community-based care coordination network. Community Health Workers (CHWs) were the reason the model was originally designed. CHWs are uniquely able to engage community residents at risk for poor health and social outcomes. The PCHI Model provides training and tools for CHWs to identify risk factors and work towards eliminating those risks one by one. The model provides the infrastructure to track risk factors from identification through mitigation and link payment directly to outcomes. The PCHI Model is a quality improvement framework for communities to build their own robust network of community-based care coordination in partnership with local stakeholders to align resources and achieve positive outcomes.
A Pathways Community HUB (PCH) is an organized, outcome focused, pay for performance network of community-based organizations that hire and train 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.
A Pathways Community HUB must be neutral, transparent, and accountable to the community. To remove silos and eliminate duplication of services, there is only one PCH in a community or region. The PCH does not employ CHWs, but contracts with existing organizations – Care Coordination Agencies (CCAs) – that hire CHWs and their supervisors. Everyone in the PCH network agrees to use the PCHI Model to collect data in a standardized way – including data collection tools, Standard Pathways to track risk factors, and standard reports. The data that is gathered by the PCH network is presented to the Community Advisory Council for review and action.
Our Current System
In our current system of healthcare and social services, services are provided to the individual and may be “siloed” in their provision of services. Imagine this family: a single mother is pregnant with her second child. Her four-year-old daughter is asthmatic, though undiagnosed, and they are living with grandma, a Type 2 Diabetic who smokes. Mom must not only manage contacts with multiple agencies for her own needs but also those necessary for her daughter’s health, and possibly for grandma, as well.
This approach can lead to individuals and families having to repeat their story to numerous providers in efforts to receive the care they need. It can also result in services being missed. Not only can this can be confusing and difficult to navigate, but it can also result in duplication of efforts by providers trying to meet the needs of the family.
The HUB System
The Pathways Community HUB Model provides the opportunity to change our system to one that allows for a more efficient and effective way to provide holistic care to families in our community.
Instead of a family having to navigate multiple people from multiple agencies, the Community Care Coordinator assigned to the entire family identifies each individual’s risks, identifies outcomes to achieve (Pathways) to reduce their risk and navigates the family through the systems to obtain the services they need. This helps to streamline the acquisition of services for families and improves communication to service providers for more effective care.
Referrals may only be made through specific referral sites via an electronic portal connected to the Great Rivers HUB database. Other referrals may be possible through existing Care Coordination Agencies (CCAs) that are providing Community Care Coordination in the community.
For more information, please contact the applicable HUB Operations Manager: