The San Joaquin Community Foundation was selected by a local group of public health advocates and funders to serve as the administrator for an innovative approach to community-based healthcare called Pathways Community HUB. A Pathways Community HUB (PCH) creates a sustainable, community-based care coordination system empowering Community Health Workers to identify individuals with modifiable risk factors (medical, social, behavioral) and develop relationships to connect them to services and track the outcomes with a goal to reduce health disparities.  

The Pathways Community HUB Institute’sSM (PCHI) Model provides the framework to build a robust, complete network of care that removes the barriers and improves systems while also reducing duplication of services and aligning payment with achieving positive outcomes. In other words, the PCHI Model is a transparent accountability framework for communities to meet their specific health improvement goals. 

How the Model Works

Local community health workers engage with families to connect them to social and medical services.
Services are designed to identify and lesson barriers to health, or risk factors, across 21 standardized Pathways such as lack of housing or inadequate access to specialized health services.
Each Pathway outlines the steps needed to identify and lessen health risks. The Community Health worker's are tasked with helping the participant identify and address the risk through support and connection to resources.
Pathways are completed when the barrier or risk has been lessened.
Payment for services are tied to the completion of healthy behavior improvement Pathways.


California Health Care Foundation

Dignity Health St. Joseph’s Medical Center

CommonSpirit Health Foundation

Abbott Fund

Pathways Community Hub Institute

San Joaquin Community Foundation