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Pathways Community HUB

The Pathways Community HUB (PCH) 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, behavioral health, and social needs.

The Pathways Community HUB (PCH) Community Health Workers (CHW) will provide community members with ongoing intensive care coordination to ensure that the individuals and their families receive the services to mitigate their risk and to address any barriers that might arise (transportation, child care services, etc.). 

An individual’s risks are identified through 21 standardized Pathways that are identified during an individual’s first visit with a PCH CHW. After Pathways are identified, the CHW will work with the individual and their family until the Pathways are completed or are no longer required. 

21 Standardized Pathways that mitigate risk:

  • Maternal Care

    • Family Planning
    • Pregnancy
    • Post-Partum

  • General Care

    • Developmental Referral
    • Health Coverage
    • Immunization Referral
    • Learning
    • Medical Home
    • Medical Referral
    • Oral Health

  • Behavioral Health

    • Mental Health
    • Substance Abuse

  • Medication Management

    • Medication Adherence
    • Medication Reconciliation
    • Medication Screening

  • Social Services

    • Adult Education
    • Employment
    • Food Security
    • Housing
    • Transportation
    • Social Service Referral

Contact Info

For more information, call (702) 616-4922. 

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