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  • Writer's picturePCHI

PCHI offers solutions for hospitals, health systems to partner with communities

Maumee, OH – Pathways Community HUB Institute® (PCHI®) - a leading, national nonprofit that has developed a transformative community health worker care coordination model that helps communities work together to support their under-resourced populations – is excited to announce the development of a comprehensive guide for hospitals and health systems to learn more about how to partner with their communities and address the whole picture of patient care – medical, social and behavioral – in a financially sustainable way.

“PCHI is here because we’ve seen first-hand the impact that a community-designed care coordination network can have on individuals and their families. By championing, investing in, and supporting the PCHI® Model, healthcare providers are better positioned to address patients’ non-clinical needs, improve health outcomes and reduce health disparities,” said Jan Ruma, President and CEO, Pathways Community HUB Institute. “The PCHI healthcare guide is here to educate health providers about the PCHI Model, ways they can become involved in their own communities and how successful, non-duplicative community care coordination breaks down barriers that affords access to care and services for all.”

Two health care providers – CommonSpirit Health and ProMedica - are profiled as key examples of how providers can champion the PCHI Model in the communities they serve.

Through its partnership with PCHI, CommonSpirit is bringing the PCHI Model to six communities in six states where it offers services, making it the largest effort by a health system to champion the implementation of the Model across multiple states and cities at one time. According to Ji Im, Senior Director of Community and Population Health for CommonSpirit, thanks to standardized processes, Pathways, and tracking of outcomes, the Model gives communities the roadmap to implement an outcome-oriented, collaborative, community-based care coordination network.

“There’s validity in the PCHI Model because it is the first community care coordination model to tie outcomes to payment. PCHI has engaged with health plans and providers to create a necessary funding model. And it provides structure around the work which utilizes community health workers to engage with residents and connect them to resources and care,” Ms. Im said.

ProMedica – based in Toledo, Ohio - serves as a care coordination agency affiliated with the Northwest Ohio Pathways Community HUB (PCH) – a neutral entity that brings hospitals, organizations and payers together to successfully impact health and well-being. As a contracted care coordination agency, ProMedica employs CHWs who support individuals referred by the Northwest Ohio PCH and is paid for completed Pathways through contracts held by the PCH with several payers. Additionally, the Model enabled ProMedica to successfully deploy PCH CHWs across its system of care.

“By looking at the social determinants of health, we’re working to address the root of what makes individuals healthy which includes their lifestyle, access to food, financial stability, employment, etc. While this work is not easy, health systems can no longer simply sit in silos to try and create solutions,” said Kate Sommerfeld, President, Social Determinants of Health, ProMedica. “It takes a village and integration across all sectors of a community to work together to support under-resourced individuals.”

The 24-page document is now available via the PCHI website:

“As more hospitals and health systems are held to rigorous quality improvement metrics and outcomes, having a standardized, community led care coordination approach is critical. The PCHI Model assists communities in breaking down barriers, engaging partners and increasing positive patient outcomes–it’s a win-win approach for everyone involved,” said Sarah Redding, MD, Founder of PCHI and the PCHI Model.


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