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  • Writer's picturePCHI

Question & Answer: Connecting with Pathways Community HUBs

PCHI is pleased to introduce a new, ongoing series of Q & A’s introducing Pathways Community HUBs and the impact they have in communities across the U.S.


Recently, PCHI sat down with Vanessa Southworth, Director of the Winona Community HUB in Winona, Minnesota, to discuss the Pathways Community HUB and the important work it’s doing. Winona is a city of about 26,000 located in southeast Minnesota on the banks of the Mississippi River. Winona Community HUB began operating in 2019 and became a certified level 1 Pathways Community HUB through PCHI in the Fall of 2022.


Why did Winona create a Pathways Community HUB within the community and what were your initial goals?

The Winona Wellbeing Collaborative (WWC), established in 2016, is comprised of partner organizations dedicated to addressing the social determinants of health and eliminating barriers for area residents facing health inequities. The WWC focused its efforts on addressing the fragmentation and silos that exist between agencies and providers, leading to the implementation of the Pathways Community HUB Institute (PCHI) Model. The Model emerged as the most advanced evidence-based framework for community-based care coordination, and we worked with PCHI and the community to then develop the Winona Community HUB. 


You mention the WWC partnered with many across the community. Can you share all those involved.

The Winona Community HUB is a testament to the collaborative efforts of our community’s agencies, providers, funders, and organizations. Together, we have forged partnerships to ensure that our under-resourced residents have access to the essential services and care they need to move forward toward improved wellbeing.

While it’s a long list, I would be remiss if I didn’t name all those involved from the ground up to create the Winona Community HUB. It truly is a community effort, and we are thankful to everyone involved.

  • Winona Wellbeing Collaborative Member Agencies: Catholic Charities of Southern Minnesota, Family & Children’s Center, Minnesota Community Health Worker Alliance, Minnesota Department of Health Center for Health Equity, Project FINE, Winona Area Public Schools, Engage Winona, Winona County Health & Human Services, Winona Health, Winona Volunteer Services

  • Funders: Blue Cross and Blue Shield of Minnesota, Ucare, Stratis Health Building Healthier Communities Grant, Minnesota Department of Health Center for Health Equity Grants, Blue Cross and Blue Shield of Minnesota Foundation Grant, and The American Rescue Plan Grant

  • Community Care Agencies: Winona Health, Family & Children’s Center, Catholic Charities of Southern Minnesota

  • Formal Referral Partners: Advocacy Center of Winona, Catholic Charities of Southern Minnesota, Family & Children’s Center, Habitat for Humanity, Hiawatha Valley Mental Health Center, Miller Mentoring, Winona Area Public Schools, Winona County Health & Human Services, Winona Family YMCA, Winona Health, Winona Volunteer Services


As the partners came together what concerns or problems did you identify that needed to be addressed?

The initial goal of the Winona Community HUB was to address food insecurity in our community, based on the needs identified in the 2016 community health needs assessment. However, as the Pathways Community HUB evolved and community health workers (CHWs) met with residents our focus grew to also include housing insecurity, mental health concerns, and those individuals with five or more emergency department visits in the past 12 months. In fact, the results from the 2022 community health needs assessment showed a need for mental health and wellbeing, health equity, healthy behaviors, and social connectedness.  


What Pathways have been the hardest to close and/or to navigate? Why? 

While there are several Pathways that have posed challenges for the Winona Community HUB, each challenge reinforces the need for the work we do and the services we provide. Here’s a snapshot of some of those Pathways and the reasons behind their complexity.

  • Housing: the community has limited affordable housing options and long waitlists for new mental health-focused housing programs. The median duration of days it took to complete the Housing Pathway in 2022 was 102 days.  

  • Oral Health: there is a limited number of providers in the area accepting new patients or providers that accept Medicaid. Many Winona Community HUB participants are referred to oral health providers in nearby towns (30 to 50 miles outside of the PCH’s service area). The median duration of days it took to complete this Pathway in 2022 was 49 days. 

  • Mental Health: the community has few mental health professionals (especially for specialty mental health services, like psychiatry and substance use), and, as a result, the wait times for new patients are long. The median number of days it took to complete the 2022 Mental Health Pathway was 70 days. 

  • Substance Use: With limited providers in the area, it took, on average, about 80 days to complete this Pathway in 2022. Additionally, it’s important to mention this Pathway includes tobacco use, which means that CHWs often mark this as “closed incomplete” because participants decline further services and follow-up.  

  • Employment: A common barrier among participants is finding sustainable employment due to previous criminal convictions on their record. Another common trend we observe is the inability to follow up with participants who do begin a job. They often don’t respond to their CHWs follow up calls, thus we are unable to verify whether the participant is still employed at their 30-day mark. Additionally, it is difficult to navigate employment for people who do not have a valid Social Security Number. The median duration of days it took to complete the Employment Pathway in 2022 was 58.5 days.


Where do you see the opportunities for the Winona Community HUB moving forward?

The two biggest opportunities for the Winona Community HUB moving forward are staffing and funding. Because we are a rural community, there is not an abundance of community health workers in the area. In fact, we were the first organization in the area to hire CHWs. Because CHWs are required to enroll in the certificate program it can end up delaying their billable status for up to 18 months. It has also been a juggling act for the CHWs to work full-time while attending such courses, resulting in a challenge to recruit and retain. However, thanks to more scholarship and apprenticeship opportunities through the State of Minnesota, we are hopeful people will take advantage of those and inquire about becoming a CHW.


Funding challenges are the result primarily from current legislative rules in Minnesota. Health education is technically the only billable service for CHWs. We have been working with the Minnesota Community Health Worker Alliance, and there is positive momentum with DHS, to expand the scope of billable services to include systems navigation. In the meantime, we continue to seek out grant opportunities.


Can you share some of the outcomes you’ve seen? 

Since the Winona Community HUB started in 2019, here are the following outcomes we’ve observed through successful completion of Pathways:

                                                i.    Housing: 74  

                                               ii.    Medical Referral: 608  

                                              iii.    Social Service Referral: 619 

                                             iv.    Medical Home: 58 

                                               v.    Healthcare Coverage: 42 

                                             vi.    Mental Health: 68 

                                            vii.    Learning: 698 

                                           viii.    Employment: 49 

                                             ix.    Pregnancy: 11 


The most closed Pathway sections are Medical Referrals, Social Service Referrals, and Learning Modules. These go hand in hand with addressing health equity by improving access to care and resources and ensuring participants are equipped with the skills, support, and health education to navigate the health and social service system.  


What has been the response from those you assisted? We understand confidentiality is important so no names or likeness will be used.

There are several amazing stories to tell. The Winona Community HUB is making a difference because our community is coming together to provide services and support to residents in need. Here are a couple of short stories of those being helped:

  • When B started with the Winona Community HUB he was homeless, new in town, and in residential treatment. The CHW assisted B with getting signed up with WRAP+, obtaining mental health services such as psychiatry, therapy, ARMHS, and CBT. CHW also assisted B with filing for SNAP, general assistance, and Social Security disability as well as helped in obtaining a birth certificate, ID, SSN card, and housing. B was provided important health education that supports his mental health, high cholesterol, family planning (vasectomy), and smoking cessation. “Because of my CHW, I’m on a better path, and I’m staying on track with my health and recovery,” B stated.   

  • P – who is disabled - moved to Winona for a better environment and was temporarily staying with a cousin. P had unmet mental health needs, housing insecurity, and in need of support services. P’s CHW assisted in filing paperwork with Winona HRA and after six months was housed. During that time, CHW also helped P to connect with regular therapy sessions, follow medication adherence for hypertension, high cholesterol, and depression; establish dental care and preventive care screenings like eye exams. P With the CHWs guidance, P was able to be set up with Winona County case management, ARMHS, SEMCIL, and is currently enrolled in GED courses. P is also on a waitlist for disability employment services.


What’s been the most rewarding aspect of the work by Winona Community HUB? 

Everything we do is guided by our community’s health and wellness. We advocate for a better community and work to advance health equity. Seeing the measurable impact of improved health outcomes for participants, and knowing that their basic health needs are met, is not only gratifying but also a testament to our CHWs and their dedication to building trust and respect with those they serve. Last year, we established a Participant Advisory Council (PAC), where a diverse group of Pathways Community HUB participants provide feedback on their experiences. It’s rewarding to hear from them and witness their empowerment as they share their ideas and thoughts, knowing that they are being heard.


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