Pathways Community HUB Model Overview

The Pathways Community HUB model focuses on the comprehensive identification and reduction of risk in a culturally connected pay-for-performance approach. Community based care coordination organizations employ community health workers (CHWs) to reach out to those at greatest risk of poor health outcomes.  The CHWs complete a comprehensive assessment of health, social, and behavioral health risk factors for the individuals they serve.  Working with a team of social workers and medical personnel, a risk reduction plan of care is developed. Each risk factor identified in the assessment is assigned a specific Pathway which is tracked and can provide confirmation that the risk factor is addressed. Pathways and the related reduction of risks span access to health care, housing, food stability, education, employment and other areas of concern. Programs delivering nationally certified Pathways Community HUB (HUB) services are paid when each Pathway (risk reduction) is completed.

The HUB represents a network of agencies that provide evidence-focused care coordination and the professional work needed to identify and address risk factors. The HUB, as the quality center of the network, assures that care coordinators and programs collaborate in their approach to identify and address risk, reduce service duplication and increase the effectiveness of systems of care (Agency for Healthcare Research and Quality, 2016).

Through the HUB, community based service providers are demonstrating that it is possible to pay directly for confirmed risk factor reduction. This lens of risk reduction tying payment directly to confirmed mitigation of critical factors of risk within a comprehensive approach may have effective application in a pay for value strategy for providing health and social services. Funders currently supporting HUBs include Medicaid managed care plans, health departments, social service agencies, private foundations, community mill levies, United Way, churches and others. Funders realize a direct link between confirmed risk reduction and payment. Given this array of current funding applications, it seems likely that the HUB Pathways model can be braided and integrated with a wide range of health and social service funders. 

The Pathways Community HUB initiative is still relatively small, but it is being implemented in multiple communities in eight states.  The span of care coordination services extends from infancy through adults and elders.  Health, social and behavioral health factors are all required components of risk identification and reduction. Initial publications have described and demonstrated improved outcomes and reduced cost of care (Alley, et al, 2016; Redding, et al, 2015). Like most other programs in the health and human services area, the scientific information produced from this initiative could be critically helpful in furthering improvement of the HUB related programming and payment structure. The Pathways Community HUB Certification Program (PCHCP) within PCHI holds the national standards and certification of HUBs, and has committed to modification of the standards based on the available scientific evidence.