Best Practice

Pathways Community HUB Institute (PCHI)


State/Jurisdiction: Ohio
Setting: Community
Population: Cross-Cutting/System Building,
Topic Area: Service Coordination & Integration, Workforce Development & Leadership
NPMs: NPM 1: Well-Woman Visit NPM 3: Risk-Appropriate Perinatal Care NPM 4: Breastfeeding NPM 5: Safe Sleep NPM 6: Developmental Screening NPM 10: Adolescent Well-Visit NPM 11: Medical Home NPM 12: Transition NPM 13.1: Preventative Dental Visit – Pregnancy NPM 13.2: Preventative Dental Visit – Child/Adolescent NPM 14.1: Smoking – Pregnancy NPM 14.2: Smoking – Household NPM 15: Adequate Insurance

The Pathways Community HUB Institute (PCHI) supports communities and community health workers (CHWs) in improving health and social equity through the Pathways Community HUB model. This approach encompasses community network development guidance, incentives for community-based organization collaboration, client and family risk assessments, CHW training, Pathways risk-mitigation workflows to confirm that outcomes are achieved, as well as billing and common reporting and benchmarks. When combined, these tools help communities in their initiatives to improve health equity and measure success of those initiatives. With published evidence of both outcome improvement and cost savings, the Pathways Communith HUB (PCH) approach and its national certification is officially recognized by both payers and policy makers focused on pay for outcomes. The PCHI team assists communities to develop systems to address individually modifiable risk factors (spanning medical, social, and behavioral, and oral health), to effectively identify and address needs by capitalizing on the strong, trusting relationships CHWs develop over time with the individuals and families they serve. Many individually modifiable risk factors hinge on changes in client behavior related to things like nutrition, education, parenting, or compliance with medical care. CHWs, who regularly visit clients in their homes, are in a unique role to be able to support coordination of care, as well as coach and support individuals to learn new skills, get access to needed services, and make vital behavioral changes to improve their health and social outcomes. The Pathways methodology used by the CHWs adds an accountable mechanism to be able to identify and track risk mitigation for evaluation and payment purposes.


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