Thank you for visiting the Harris County Pathways Community HUB webpage within the Network of Behavioral Health Providers website. The Harris County Pathways Community HUB is no longer operating. The information below is maintained as an archive documenting the program's implementation, accomplishments, and impact on coordinated care in Harris County. For information about NBHP's current initiatives, please visit our current programs or contact us.
NBHP Successfully Achieved National Certification
Through the Pathways Community HUB Institute®
The Harris County Pathways Community HUB was a two-time nationally certified Pathways Community HUB through the Pathways Community HUB Institute® (PCHI®). Its primary objective was to connect high-risk Medicaid beneficiaries, Medicaid-eligible individuals, and uninsured adults with essential health and social services to address non-medical factors affecting their overall health and well-being. The program served individuals living with mental health conditions, substance use disorders, as well as those who were pregnant or up to 12 months postpartum with behavioral health risk factors.
The HUB operated using the Pathways Community HUB Institute’s® (PCHI®) evidence-based, home-visitation, data-driven, pay-for-performance model of care coordination. Through this nationally recognized model, certified Community Health Workers (CHWs) provided individualized care coordination, long-term support, health education, and resource navigation to help participants overcome barriers to care and improve health outcomes. By opening and successfully closing evidence-based "Pathways," CHWs worked alongside participants to address health-related social needs, including food insecurity, housing instability, access to behavioral health services, medication adherence, health insurance coverage, and pregnancy and postpartum care.
Throughout its implementation, the Harris County Pathways Community HUB strengthened cross-sector collaboration among healthcare providers, behavioral health organizations, and community-based partners, demonstrating the value of coordinated, person-centered care in improving health equity and addressing the social drivers of health.
Through the Pathways Community HUB Institute®
The Harris County Pathways Community HUB was a two-time nationally certified Pathways Community HUB through the Pathways Community HUB Institute® (PCHI®). Its primary objective was to connect high-risk Medicaid beneficiaries, Medicaid-eligible individuals, and uninsured adults with essential health and social services to address non-medical factors affecting their overall health and well-being. The program served individuals living with mental health conditions, substance use disorders, as well as those who were pregnant or up to 12 months postpartum with behavioral health risk factors.
The HUB operated using the Pathways Community HUB Institute’s® (PCHI®) evidence-based, home-visitation, data-driven, pay-for-performance model of care coordination. Through this nationally recognized model, certified Community Health Workers (CHWs) provided individualized care coordination, long-term support, health education, and resource navigation to help participants overcome barriers to care and improve health outcomes. By opening and successfully closing evidence-based "Pathways," CHWs worked alongside participants to address health-related social needs, including food insecurity, housing instability, access to behavioral health services, medication adherence, health insurance coverage, and pregnancy and postpartum care.
Throughout its implementation, the Harris County Pathways Community HUB strengthened cross-sector collaboration among healthcare providers, behavioral health organizations, and community-based partners, demonstrating the value of coordinated, person-centered care in improving health equity and addressing the social drivers of health.
Impact Story: Overcoming Barriers
Through Coordinated Care
When Amina (name changed for privacy), a Harris County resident from the Afghan community, enrolled in the Pathways Community HUB, she was in the last days of her final trimester of pregnancy and facing multiple risks that threatened her health and stability.
With limited English proficiency and no family support nearby, Amina’s circumstances grew more complicated after she gave birth to her baby. Shortly after delivery, she lost her SNAP benefits due to an administrative issue, her housing situation became unstable, and she lacked consistent access to healthcare, transportation, and community resources.
That’s when the HUB, through the work of a dedicated Community Health Worker (CHW), stepped in to walk alongside her. The CHW built trust with Amina and became a consistent point of contact, guiding her through the process of stabilizing her household.
Pathways Activated:
Through Harris County Pathways Community HUB’s holistic, equity-focused approach, Amina transitioned from crisis to stability. The CHW’s role was pivotal in helping her overcome barriers that could have easily led to long-term hardship. Today, Amina is raising a healthy baby in a safe home environment and is connected to community supports that strengthen her family’s resilience.
Through Coordinated Care
When Amina (name changed for privacy), a Harris County resident from the Afghan community, enrolled in the Pathways Community HUB, she was in the last days of her final trimester of pregnancy and facing multiple risks that threatened her health and stability.
With limited English proficiency and no family support nearby, Amina’s circumstances grew more complicated after she gave birth to her baby. Shortly after delivery, she lost her SNAP benefits due to an administrative issue, her housing situation became unstable, and she lacked consistent access to healthcare, transportation, and community resources.
That’s when the HUB, through the work of a dedicated Community Health Worker (CHW), stepped in to walk alongside her. The CHW built trust with Amina and became a consistent point of contact, guiding her through the process of stabilizing her household.
Pathways Activated:
- Postpartum Pathway – ensuring follow-up medical visits for mother and baby, mental health screening, and breastfeeding support.
- Housing Pathway – helping her apply for emergency rental assistance and connecting her to culturally sensitive housing support services.
- Food Security Pathway – assisting with re-establishing SNAP benefits, linking her with food pantries, and ensuring immediate food access after her benefits lapsed.
- Transportation Pathway – arranging rides for post-partum appointments through local partner agencies.
- Insurance Coverage Pathway – helping her navigate Medicaid eligibility for herself and her newborn.
- Employment/Education Pathway – later helping her explore job readiness programs to strengthen long-term stability.
- Within 1 month, Amina’s food insecurity was addressed through emergency pantry referrals while her SNAP benefits were reinstated.
- Within 4.5 months, she secured stable housing through a temporary housing program while awaiting placement in more permanent housing.
- By 6 months, Amina completed all postpartum follow-up care, her baby was fully enrolled in pediatric services, and she began engaging in ESL and workforce readiness programs.
- After 9 months, with continued CHW support, Amina reported feeling more confident in navigating systems, had reliable childcare, and was on a path toward employment.
Through Harris County Pathways Community HUB’s holistic, equity-focused approach, Amina transitioned from crisis to stability. The CHW’s role was pivotal in helping her overcome barriers that could have easily led to long-term hardship. Today, Amina is raising a healthy baby in a safe home environment and is connected to community supports that strengthen her family’s resilience.
Funding Partners
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Program Legacy
During its operation, the Harris County Pathways Community HUB demonstrated the value of integrating behavioral health, healthcare, and community-based organizations through a coordinated care model. The initiative strengthened partnerships across healthcare systems, social service organizations, and community health workers while advancing equitable approaches to addressing social drivers of health.
Lessons learned from this initiative continue to influence collaborative care coordination efforts throughout the region.
Key accomplishments included:
• Building one of Texas' nationally certified Pathways Community HUBs.
• Strengthening cross-sector collaboration among behavioral health, healthcare, and community organizations.
• Demonstrating how Community Health Workers can effectively address social drivers of health.
• Creating sustainable quality improvement processes through nationally recognized standards.
During its operation, the Harris County Pathways Community HUB demonstrated the value of integrating behavioral health, healthcare, and community-based organizations through a coordinated care model. The initiative strengthened partnerships across healthcare systems, social service organizations, and community health workers while advancing equitable approaches to addressing social drivers of health.
Lessons learned from this initiative continue to influence collaborative care coordination efforts throughout the region.
Key accomplishments included:
• Building one of Texas' nationally certified Pathways Community HUBs.
• Strengthening cross-sector collaboration among behavioral health, healthcare, and community organizations.
• Demonstrating how Community Health Workers can effectively address social drivers of health.
• Creating sustainable quality improvement processes through nationally recognized standards.
Harris County Pathways Community HUB
Program Impact
Understanding and Implementing the Pathways Community HUB Institute® Model
Program Leadership
The Harris County Pathways Community HUB was launched to transform how individuals with complex health and social needs accessed coordinated care. Under the leadership of LaToya Shields, MPA, BSW, CHW, the program achieved two national certifications through the Pathways Community HUB Institute®, implemented an evidence-based care coordination model, built a network of healthcare and community partners, and established quality improvement processes that advanced health equity across Harris County. These accomplishments continue to reflect NBHP's commitment to innovative, collaborative approaches that address access to care.
The Harris County Pathways Community HUB was launched to transform how individuals with complex health and social needs accessed coordinated care. Under the leadership of LaToya Shields, MPA, BSW, CHW, the program achieved two national certifications through the Pathways Community HUB Institute®, implemented an evidence-based care coordination model, built a network of healthcare and community partners, and established quality improvement processes that advanced health equity across Harris County. These accomplishments continue to reflect NBHP's commitment to innovative, collaborative approaches that address access to care.
| Final Report & Business Plan (December 2021) |
Network of Behavioral Health Providers
9401 Southwest Freeway Suite #1242
Houston, TX 77074
Phone: 713-970-3410
9401 Southwest Freeway Suite #1242
Houston, TX 77074
Phone: 713-970-3410