The Pathways Community HUB Institute (PCHI) grew out of the original work of CHAP, the Community Health Access Project. PCHI provides the national HUB Certification standards in {with the} support of the Rockville Institute Certification process.  PCHI represents multiple layers of national guidance from research, community members, payers and policy makers to inform and continue to improve the model.  PCHI provides technical support and guidance to those considering and actively developing HUBs within their own regions.  Coalitions are now able to improve health outcomes, address disparities in health and reduce costs through the Pathways Community HUB model.   PCHI has been a leader in:





The United States spends significantly more money per capita on health care services than any other nation in the world and lags behind most other developed countries in key outcome measures. The primary sources of these adverse health and social outcomes are risk factors.
To address risk factors communities need to develop standardized, organized and effective care coordination networks focused on the comprehensive identification and reduction of risk. The purpose of the HUB is to provide an organized, evidence based approach for a network of agencies to identify {and address} the populations most at risk within a community.
Finding the specific individuals within communities who are most likely to have a poor health outcome, addressing their specific needs, and accountably measuring their results will influence the overall health of the individual and the community. The first community that piloted the HUB model demonstrated with peer reviewed publication a significant improvement in low birth weight for individuals enrolled as well as a countywide reduction in low birth weight


TITLE V/MCH BLOCK GRANT MEASURES ADDRESSED. {perhaps goes somewhere else?}

#01: Percent of women with a past year preventive visit
#03: Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU) #11: Percent of children with and without special health care needs having a medical home

The model is being utilized in all age groups with an emphasis on maternal and child health.


Within an organized multiagency network of community care coordination,

  • Accomplish outcome improvement through identifying at risk individuals, and assuring their health, behavioral health, and social service risk factors are identified and addressed.

  • Support a model certification structure for community networks that utilize a standardized approach for reaching out to those at greatest risk, and assure identified risk factors are addressed using Standardized Pathways. Health, social and behavioral health risk factor reduction is the focus, achieving individual and population based outcome improvements.

  • Provide an accountable framework for communities who want to build an effective network.

  • Provide standardized mechanisms for data reporting and continual quality improvement.

  • Provide community networks an evidence based approach that they can utilize to collaborate effectively and market to funders for sustainability.

  • Provide funders and policy makers assurance that community networks have met specific operational, health outcome and cost of care improvement benchmarks.