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. 

Current Opportunity

Current Opportunity to serve as an inaugural Pathways Community HUB Care Coordination Agency employing Community Health Workers to provide Care Coordination for African American Pregnant Individuals. See the Request for Application below, also available in PDF.

The application deadline is March 31, 2023.

Maternal Health

Community-Based Organizations interested in employing Community
Health Workers to provide Home Visiting Care Coordination to improve
Black Maternal Health in San Joaquin County

FROM: Nadeja M. Steager, Director of The San Joaquin County Pathways Community HUB on behalf of the HUB Core Team

DATE: March 6, 2023
RE: Opportunity to serve as an inaugural Pathways Community HUB Care
Coordination Agency employing Community Health Workers to provide
Care Coordination for African American Pregnant Individuals.

The Pathways Community HUB at the San Joaquin Community Foundation (PCH) is a demonstration project to implement the Pathways Community HUB Institute ® Model (PCHI Model) that is directed by a Core Team of Community Leaders. This pilot is focused on individualized family support to improve birth outcomes by reducing the incidence of low birth weight (LBW), preterm babies and infant mortality
in targeted high-risk areas in San Joaquin, CA. The project is currently funded by the California Health Foundation, Dignity Health, CommonSpirit Health Foundation, Abbott Fund and San Joaquin Community Foundation.

We are currently seeking applications from Community-Based Organizations that currently have community health workers (CHW) on staff or are willing to hire and supervise CHWs to be trained and deployed to provide community-based care coordination through the PCHI Model. The target population is African American maternal individuals in areas of San Joaquin County with a history of poor birth outcomes. The successful applicants will be considered Care Coordination Agencies of the San Joaquin Pathways Community Hub. Priority will be given to applicants that
already have a funding source for staffing. The selected agencies will be eligible for start-up funding and engagement fees and outcome payments for successfully engaging the target population and completing health and social determinants of health Pathways. To provide clarity on the role of Community Health Workers, please see the linked sample job description for a Community Health Worker and Community Health Worker

The application deadline is March 31, 2023. Interested organizations must view the recorded information session on the Pathways Community HUB RFA linked below.

Recorded Information Session Information:
Passcode:  jH0B^v38

To access and submit the application, please see the following instructions:

  1. Go to the SJCF grants portal website:
  2. Enter your Username (email address) and Password or click on Create New Account if you have not set up an account in our system. 
  3. Click on “Apply” at the top left of the screen next to the home icon.
  4. Find the “Care Coordination Agency (CCA) Pilot Application” notice and click on the blue “Apply” button to begin the application.
  5. Click “Submit Application” at the bottom of the application or “Save Application” to finish your application at a later date.

Questions must be submitted via email to Nadeja M. Steager, Director of The San Joaquin County Pathways Community HUB:

For technical assistance with the online grant application, please contact George Lorente, Director of Grants and Scholarships: (209) 943-2375 or

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