top of page

Based Payment

PCHs bill Medicaid managed care plans and other funding partners after successfully completing Pathways ensuring clients needs are addressed.

Coordinated Care

CHWs help clients develop a care plan based on identified risks and needs and use Pathways Learning Modules to help clients learn how they can improve their health.

Community HUB

Pathways Community HUBs (PCHs) work with community-based organizations, agencies, and providers, to build a large network of available services.

Health Workers

Trained CHWs from the communities they serve meet regularly with clients, build relationships, and assess needs and risks based on our 21 Standard Pathways.

The Pathways Community HUB Institute® Model

The 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.

Pathways Community HUB (PCH)

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.

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.

21 Evidence-based Pathways

Pathways are tools used by CHWs to identify and track individually modifiable risk factors. A Pathway is closed when a measurable outcome, which is meaningful to the participant, is achieved. If an outcome is not reached, then a Pathway is closed “finished incomplete,” but the CHW’s efforts to resolve the risk are recorded for evaluation. In the PCHI Model, 50 percent of payments to the Pathways Community HUB and Care Coordination Agencies are directly tied to closed Pathways.

Adult Education

Developmental Referral


Family Planning

Food Security

Health Coverage


Immunization Referral


Medical Home

Medical Referral

Medical Adherence

Medical Reconciliation

Medical Screening

Mental Health

Oral Health



Social Service Referral

Substance Use


In Home Community-Based Care Coordination

The PCHI® Model uses a simple, but powerful, tool for CHWs to identify risk factors of residents enrolled in the PCH—relationships! CHWs need time to build trusting relationships with residents and should not be thought of as data gatherers. The PCHI Model Visit Form provides a conversational approach for CHWs to determine risks. Each risk factor is translated into one of the 21 Standard Pathways for tracking. The PCHI Model is built on in-home or community-based visits by CHWs.

Photo Courtesy of Northwest Ohio Pathways HUB

Learning Pathways to Wellness

Individually modifiable risk factors span medical, social, behavioral and safety domains. The Pathways Community HUB Institute® Model provides more than 50 Pathways to Wellness Learning Modules to be used with the Learning Pathway. These modules include the most up-to-date evidence available, for CHWs to engage in educational, interactive conversations with their clients to understand their condition or to help make behavioral changes. 

Quality Benchmarking and Quality Improvement

Measurement is key to the Pathways Community HUB Institute® Model. PCHI relies on quality data to continuously make improvements to the Model, publish new evidence about its impact, and to demonstrate the Model’s efficacy to funders. PCHI’s Quality Benchmark Report (QBR) is a required data reporting tool for Certified Pathways Community HUBs and Pathways Agencies. Quarterly reports are provided to PCHI, and the data is aggregated to develop quality and performance reports.

Outcome-Based Payments

A foundation of the PCHI® Model is the outcome-based unit (OBU) payment methodology. Each Standard Pathway has a unique billing code and modifier assigned to it. In addition, an outcome-based unit accompanies each Pathway and is a measure of the complexity and time needed to successfully complete the Pathway. For example, the Housing Pathway has an OBU value of 15 to confirm that a resident has moved in to safe and stable housing and is there 30 days later. The Learning Pathway has an OBU of 0.5 to confirm that the CHW has provided a PCHI Model Learning Module.


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.

Pathways Agency

Developing a Pathways Agency (PA) within a community can be an important first step to improving community-based care coordination. A single PA adopts the PCHI® Model and uses the standard data collection tools and 21 Pathways. The PA directly hires community health workers and supervisors to work with residents served by that agency. There are 18 Standards that must be met to achieve PCHI Model Certification – Pathways Agency. The PA commits to collaborating with community partners on the future development of a Certified Pathways Community HUB.

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.

bottom of page