The Pathways Community HUB Institute Mission

Better Health More People Less Cost

  • Develops tools, educational resources and certification standards

  • Provide technical support to redesign local delivery systems to create Pathways Community HUBs  

  • Coordinates and leads research

  • Policy and advocacy


Page 2:

Redesign your local delivery system to organize and integrate social, clinical and behavioral health services.  Make profitable decisions using data-driven analytics powered by the Pathways Community HUB model.

Individuals with multiple community care coordinators (CCCs) are best served with one CCC.  Re-designing the community-based care system through the Pathways Community HUB model (PCHM) improves outcomes and produces cost-savings.  Learn how the PCHM assigns one CCC to individuals/families, completes social determinant/clinical/behavioral needs assessments, assigns evidence-based interventions and tracks results. 


Page 3:


The Pathways Community HUB Model (PCHM) is a comprehensive, evidence-based community care coordination system.  The PCHM is used to identify those at greatest risk of poor health outcomes, connect them to evidence-based services and measure the results. A call for accountability by Tom Scheid, Administrator for the Mansfield Department of Jobs and Family Services inspired the inclusion of pay for performance and the first 7 Pathways were developed.  Then Samuel Star, who later became the CEO of an international technology firm, strongly suggested definition of meaningful units of work that allow accountability and payment for units of work completed.  A multi-disciplinary team was convened and created the additional Pathways used today.

The Pathways approach allows communities to build a pay for performance system and is a platform for health plans, health systems, providers, foundations, and community groups to collaborate. Data can be shared across systems to measure and control costs and document risk reduction and health results. National certification is now possible for Pathways Community HUBs to ensure quality and increase access to sustainable funding streams.

Pathways was developed with support from the U.S. DHHS (HRSA, CMS and AHRQ), the State of Ohio, national and local foundations and has been expanded through recent state legislation and financial support in multiple states. Research demonstrating improved results and cost efficiency have been published, including by the Maternal and Child Health Journal and CMS.  The Pathways Community HUB model uses and advances a value-based payment strategy and is the bridge to create mutually beneficial cross-sector partnerships. 

Page 4:


1.       Core Pathways: measurement tools to define the problem to be addressed (health or social issue), the desired measurable outcome, and the key intervention steps to achieve the outcome.

2.       Community HUB: a regional point of registry and outcome tracking that networks together health care providers, social service agencies, and health care payers that implement these Pathways.  The point of contact and the site for bridging Pathways information to the healthcare ecosystem and others.

3.       Pathway payments: payment for care coordination that is based on outcomes instead of activities.

20 Core Pathways - National Certification

Adult Education                  Behavioral Screening

Employment                        Developmental Screening

Health Insurance                 Developmental Referral

Housing                               Education

Medical Home                    Family Planning

Medical Referral                 Immunization Screening 

Medication Assessment      Immunization Referral

Medication Management  Lead Screening

Smoking Cessation             Pregnancy

Social Service Referral       Postpartum


Page 5:


The Rockville Institute operates the Pathways Community HUB Certification Program (PCHCP).  The program promotes accountable care through the certification of organizations that use formal and standardized processes in the delivery of community care coordination services.  Fundamental to certification is the use of the Pathways Community HUB Model of care coordination which promotes accountable, quality care to measurably improve outcomes and links payment to performance.  Pathways Community HUBs that use standardized Pathways and meet the eligibility requirements are welcome to apply for PCHCP certification.

Page 6:


The Pathways have been deployed to serve varied at-risk populations including maternal and child health needs, chronic adult conditions including diabetes and asthma, substance use disorders including opioid misuse and re-entry populations. 

The following organizations have benefited from deployment of the model:

  1. ACOs

  2. At-risk populations

  3. Behavioral Health/SUD providers

  4. FQHCs and private physician practices

  5. Foundations

  6. Governments - local, county, state, and federal

  7. Health Plans

  8. Health Systems

  9. Housing Service Providers

  10. Social Service Providers

  11. United Ways


More detailed information available in members section.

Page 7:


New Mexico - reported quintupling the number of successful referrals for re-entry populations 

 Michigan - estimated avoided low birth weight births range from 14 to 29 and estimated total gain avoided low birth weights newborns ranged from $34,038 to $70, 508

Ohio - reduction in low birth weight for most at-risk population from 13 to 6.1, cost savings from $3.36 to $5.59 for each dollar invested and LBW rate 8.4% for African Americans and 10.9% for Whites

Thirty-five cross-sector partnerships in one small city


More detailed information available in members section.



DELETE THE FIRST SENTENCE IN THIS SECTION AND PLACE THE REMAINDER OF THE PARAGRAPH IN THE EVENTS SECTION: PCHI is regularly invited to present at national and state meetings and webinars to share the Pathways Community HUB model. 

Center for Medicaid and Medicare "Medicaid Innovation Accelerator Program" (IAP) Maternal and Infant Health Initiative (MIHI) Value-Based Payment (VBP) team on a national webinar held May 17, 2018.  The focus was on use of VBP strategies to incentivize change in maternal and infant health care delivery models, contractual approaches that incentivze the use of innovative maternal and infant health care delivery models within Medicaid and the Children's Health Insurance Program (CHIP).




777 Nameless Ave.
New York, NY 00000

(212) 555-0110


Areas of Practice


The world of music is ever growing and evolving, and we’re not just talking about sound trends. With the consistent introduction of varying revenue streams and distribution channels, the opportunity for profit grows, but so does the complexity. That’s where we come in.


Demystifying art law is in itself a creative practice. It requires finesse, strategic structuring, and in many ways, empathy. At the end of the day, art and its worth are profoundly personal. That’s why we advise mediation or arbitration before stepping into litigation.


The way people consume entertainment is constantly in flux, so the laws must adapt quickly. Harris Ingram strives to anticipate these changes so you can focus more on creating the performance of a lifetime.


The startup and small business marketplace is still a new and fierce frontier that requires legal advice from attorneys who are deeply entrenched in the particularities of venture financing. Our firm gives you an holistic approach, so your company can get the best competitive advantage.


The internet, software, and technology are so pervasive that we can’t remember having ever lived without them. They make our lives simpler, but behind the curtain are fluctuating challenges in protection and monetization—challenges that our firm stays two steps ahead of.


Fashion law is a little bit like the Wild West. There’s a lot of potential, but the rules can seem convoluted and vague at best. Protecting a brand or even a single design involves intellectual property, copyrights, trademarks, and patents.


We must all obey the great law of change. It is the most powerful law of nature.
— Edmund Burke


Let's Chat.

Use the form below to contact us regarding your enquiry. Please be as detailed as possible. Include your industry along with any specific questions. To help us best serve you, we recommend that you first describe the issue you’re having before telling us what you want to achieve. You may also email or call us to make an appointment.

We are always looking for new ideas to strengthen the Pathways Community HUB model and individuals/organizations interested in creating comprehensive community-based care coordination systems.

Name *
Please do not include confidential or sensitive information in your message. In the event that we are representing a party with opposing interests to your own, we may have a duty to disclose any information you provide to our client.