PCHI® Model in Texas, Spotlight in Episcopal Health Foundation (EHF):
https://www.episcopalhealth.org/digging-deeper/pchimodelintexas/
Check out the PCH Program in the news: Health Tech World, 2025:
https://www.htworld.co.uk/news/products/us-community-care-programme-launches-cardmedic-to-overcome-language-barriers-and-address-health-inequities-sb25/
https://www.episcopalhealth.org/digging-deeper/pchimodelintexas/
Check out the PCH Program in the news: Health Tech World, 2025:
https://www.htworld.co.uk/news/products/us-community-care-programme-launches-cardmedic-to-overcome-language-barriers-and-address-health-inequities-sb25/
Our Pathways Community HUB Program is Nationally Certified!
Harris County Pathways Community HUB
A Simple Solution to Community-Centric Care Coordination
Harris County Pathways Community HUB is a Level 1 Certified HUB through Pathways Community HUB Institute® (PCHI®). Its primary objective is to connect high-risk Medicaid beneficiaries, Medicaid-eligible, and uninsured adults with essential services to address non-medical factors impacting their well-being. This includes individuals living with mental health conditions, substance use disorders, or those who are pregnant or up to 12 months postpartum with behavioral health risk factors. The HUB operates using The Pathways Community HUB Institute’s® (PCHI®) evidence-based, home-visitation, data-driven, pay-for-performance model of care coordination.The model leverages the expertise of certified Community Health Workers (CHWs) to provide long-term support, tailored education, and assistance in identifying and addressing risks. Through opening and closing “Pathways,” CHWs help individuals navigate various challenges, including food insecurity, access to behavioral health services, housing instability, medication adherence, health care coverage, pregnancy and postpartum care.
How We Support Our Referrals
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The Harris County Pathways Community HUB utilizes Certified Community Health Workers to provide care coordination for high-risk individuals living in Harris County. Individuals and agencies may use this form to submit a referral for care coordination services. Please note that submitting this form does not guarantee services. The information provided will help us better understand your needs and connect you with the appropriate support.
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Participant Story: Navigating Challenges with the Support of
Harris County Pathways Community HUB
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.
Harris County Pathways Community HUB
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.
Harris County Pathways Community HUB Care Coordination Agencies (CCAs)
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Pathways Community HUB Funders (2025)
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Harris County Pathways Community HUB
2024 Year in Review
Harris County Pathways Community HUB
Explaining the Implementation of Pathways Community HUB Institute® (PCHI®)
Director's Corner
LaToya Shields, MPA, BSW, CHW
LaToya Shields has been in the social service field for over 20 years. In July of 2022, she joined The Network of Behavioral Health Providers (NBHP) as the Director of Harris County Pathways Community HUB project. LaToya is passionate about empowering, serving, and supporting communities that are historically and systematically marginalized. LaToya has led and is currently leading work that disrupts inequity in maternal health services, shatters stigma surrounding substance use and mental health illnesses, and challenges harmful biases embedded in nonprofit and governmental service delivery.
LaToya holds a Bachelor’s degree in Social Work and a Master’s degree in Public Administration with a concentration in Public Policy. Both degrees were earned here in Houston, at Texas Southern University. LaToya has served as an Adjunct Professor at the University since Spring of 2021, serving in the Barbara Jordan-Mickey Leland School of Public Affairs.
For more information on the Harris County Pathways Community HUB Program, contact us at [email protected] today!
| Final Report & Business Plan (December 2021) |
| Participant Handout (June 2024) |
| Professional/Partner Handout (June 2024) |
| HCPH Flyer - Spanish - Community |
| HCPH Flyer - Spanish - Professional |
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