Pathways Community HUB
The Pathways Community HUB (PCH) Model, an evidence-based, data-driven, pay-for-performance model of care coordination, has been addressing these challenges for more than 20 years. The PCH is an entity that contracts with Care Coordination Agencies (CCAs) to hire Community Health Workers (CHWs) who meet with high-risk families in their homes and in the community in order to identify and mitigate client risk factors (more than 170 of them) through opening and closing “Pathways.”
Pathways correspond to a range of health and social service risk factors, such as food insecurity, lack of a medical home, housing instability, and behavioral health issues. The Pathways Community HUB model goes beyond a “warm handoff” or information sharing through an electronic platform—it details the steps that CHWs should take in order to resolve client risks and move them into a level of stability. When these steps are taken and a Pathway is closed, the established PCH can bill payers with whom they have negotiated contracts for the closure of the Pathways. Once the PCH receives payment, it passes on a portion of it to the Care Coordination Agency that employs the CHW that successfully completed the Pathway.
In the greater Houston area, two pilot projects used the PCH model as the basis for their care coordination efforts—The Network of Behavioral Health Providers’ (NBHP’s) Community Coordination of Care (c3) pilot project, and the Healthy Women Houston (HWH) pilot project. After recognizing the success of the c3 and HWH pilot projects in mitigating client risks, NBHP and HWH contemplated how the work of the two projects could best be continued and expanded. After several discussions, the groups decided to initiate a planning process aimed at fully implementing the PCH model in greater Houston.
Through this effort, a group of over 30 health, behavioral health, and social service organizations and collaboratives—representing over 100 organizations—met for four months throughout the summer and fall of 2021 in order to develop the framework for local PCH implementation.
The Harris County PCH is expected to launch in the Fall of 2022 and will serve Medicaid-eligible and Medicaid-receiving adults who have mental illness, substance use disorder, or are pregnant with behavioral health risk factors.
Pathways correspond to a range of health and social service risk factors, such as food insecurity, lack of a medical home, housing instability, and behavioral health issues. The Pathways Community HUB model goes beyond a “warm handoff” or information sharing through an electronic platform—it details the steps that CHWs should take in order to resolve client risks and move them into a level of stability. When these steps are taken and a Pathway is closed, the established PCH can bill payers with whom they have negotiated contracts for the closure of the Pathways. Once the PCH receives payment, it passes on a portion of it to the Care Coordination Agency that employs the CHW that successfully completed the Pathway.
In the greater Houston area, two pilot projects used the PCH model as the basis for their care coordination efforts—The Network of Behavioral Health Providers’ (NBHP’s) Community Coordination of Care (c3) pilot project, and the Healthy Women Houston (HWH) pilot project. After recognizing the success of the c3 and HWH pilot projects in mitigating client risks, NBHP and HWH contemplated how the work of the two projects could best be continued and expanded. After several discussions, the groups decided to initiate a planning process aimed at fully implementing the PCH model in greater Houston.
Through this effort, a group of over 30 health, behavioral health, and social service organizations and collaboratives—representing over 100 organizations—met for four months throughout the summer and fall of 2021 in order to develop the framework for local PCH implementation.
The Harris County PCH is expected to launch in the Fall of 2022 and will serve Medicaid-eligible and Medicaid-receiving adults who have mental illness, substance use disorder, or are pregnant with behavioral health risk factors.
Greater Houston Pathways Community HUB Final Report & Business Plan
| harris_county_pch_final_report___business_plan.pdf |
C3 Client Testimony
Network of Behavioral Health Providers
9401 Southwest Freeway
Houston, TX 77074
Phone: 713-970-3410
9401 Southwest Freeway
Houston, TX 77074
Phone: 713-970-3410