Best Practice

Pathways Community HUB Institute Model® (PCHI® Model)

State/Jurisdiction: National
Setting: Community
Population: Life Course Medical & Public Health Professionals
Topic Area: Equity & Anti-Racism Safe and Connected Communities Care Coordination Healthcare Financing & Insurance

The Pathways Community HUB Institute® (PCHI®) Model helps communities build a transformative and sustainable community-based care coordination network. The PCHI 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 community to build their own robust network of community-based care coordination in partnership with local stakeholders to align resources and achieve positive outcomes. The PCHI Model has been developed, evaluated, and scaled to many diverse communities over thirty years. It has been proven to effectively reduce costs while improving health and social outcomes for community members most at risk. It is a transformative and dramatic change from traditional care coordination, because PCHI puts the ownership of the process with communities instead of health care systems.

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