Care management services are commonly used for people with complex care needs. Growing evidence suggests that care management interventions that integrate community health workers (CHWs) — individuals who share similar health and life experiences with those they serve — can improve health outcomes. However, many community-based organizations (CBOs) employing CHWs lack the infrastructure needed to facilitate contracting with health care entities.

The Pathways Community HUB Institute (PCHI) model coordinates the administration and infrastructure for a network of CBOs and their partnerships with health care entities, with CHWs as an integral component. Currently, organizations in 48 regions across 18 states are implementing or working toward implementing the PCHI model. This profile highlights the PCHI model, illustrating how community HUBs support CHWs in addressing individuals’ health and social needs through a standardized approach and outcomes-based payment to foster community-level change.

The profile is part of the Better Care Playbook’s ongoing series, In the Field: Spotlight on Complex Care Interventions, that highlights how organizations are implementing evidence-based and promising innovations to improve care for people with complex health and social needs.