Overview of the PCHI Model
The Pathways Community HUB Institute (PCHI) was founded in Ohio in 2015 to further the PCHI Model — a transformative, standardized, and proven approach to community driven care coordination. Through national certification, training, and advocacy, PCHI innovates with communities to build capacity to create accountable networks designed to identify risk factors, reduce costs, and advance health for all. PCHI provides communities with the road map and tools they need to leverage resources to meaningfully address complex health and social needs of people who are under-resourced and at greatest risk for poor health outcomes.
Nineteen states across the country are implementing the PCHI Model to build sustainable care coordination networks in their own communities, known as Pathways Community HUBs (PCH). Within each PCH, community health workers (CHWs) engage individuals at greatest risk for poor health outcomes. As they work together, CHWs identify and track risk factors that are aligned with the 21 Pathways, which are central to the PCHI Model. Ultimately, the goal is for CHWs and participants work together to eliminate the risks one by one.
21 Pathways Explained
The 21 Pathways are unique to the PCHI Model. Each Pathway tracks an individually modifiable risk factor from identification to elimination.
For example, the Housing Pathway starts when an individual is found to be in unsafe or unstable housing. There are key steps that the CHW follows to assist in finding suitable housing. The Pathway is not closed until the individual is confirmed to be in safe and stable housing and has been there for a minimum of 30 days.
The goal of each Pathway is to confirm that a risk factor has been eliminated. Payment, which is determined through a braided funding strategy of grants, philanthropic funding, and health care payer value-based contracts, is then linked to risk reduction, defined by the completed Pathways.
Adult Education
Developmental Referral
Employment
Family Planning
Food Security
Health Coverage
Housing
Immunization Referral
Learning
Medical Home
Medical Referral
Medication 1- Screening
Medication 2- Reconciliation
Medication 3- Adherence
Mental Health
Oral Health
Postpartum
Pregnancy
Social Service Referral
Substance Use
Transportation
The PCHI Model in Texas
Episcopal Health Foundation (EHF) has provided support for four communities to successfully implement the PCHI Model through direct funding, learning convenings, and evaluation services.
Brazos Healthy Communities and Williamson County Community Health Connect were two participating sites in the Texas Accountable Communities for Health Initiative (TACHI). Created by EHF, with support from St. David’s Foundation, TACHI aims to help the six selected sites understand the health needs in their communities and think strategically about tactical ways of working together to improve health outcomes.
PCHI Models in Texas
The Early Impacts of the PCHI Model in Texas
EHF has supported two evaluation studies of the PCHI Model in Texas: Early Evaluation of the Pathways Community HUB (PCH) Model in Texas and Evaluation of Pathways Community Hub in Texas for Pregnant Mothers and their Infants. Both reports provided an overview of the rollout of the PCHI Model and understand the early impacts of the initiatives in Texas.
Key Takeaways from “Early Evaluation of the Pathways Community HUB (PCH) Model in Texas” (2024)
The Early Evaluation of the Pathways Community HUB (PCH) Model in Texas focused on communities in Brazos, Harris, and Williamson counties highlighting the early successes and limitations as each community implemented the PCHI Model. Across all three sites, the report found several notable evaluation insights:
- More than 400 clients were enrolled, most of them being Hispanic/Latino and Non-Hispanic Black, with less than 15% of clients being described as Non-Hispanic White
- The Learning and Postpartum Pathways had the highest completion rates, with Social Service Referral Pathways being the third highest for Harris and Williamson Counties and Healthcare Coverage Pathways being third highest for Brazos County PCH.
- Pathway enrollment stratified by pregnancy status highlights differential needs identified among pregnant and non-pregnant clients. For example, in Brazos County pregnant clients were significantly more likely to be enrolled in pathways focused on education (33% vs 5%).
- Pregnant people were enrolled later in their pregnancy. This finding is not unusual in programs in their first year of implementation as they work to build their referral network.
- While Pathway closure rates are informative, they may be a reflection on the local infrastructure to meet the needs of the community as opposed to the effectiveness of the PCHI Model. All three counties showed low Pathways completion rates for Adult Education, Housing, Mental Health and other non-medical drivers of health.
Key Takeaways from “Evaluation of Pathways Community Hub in Texas for Pregnant Mothers and their Infants” (2024)
The Evaluation of Pathways Community Hub in Texas for Pregnant Mothers and their Infants focused on the Bexar County PCH. The report examined the characteristics, service use, costs, and newborn outcomes of 209 pregnant mothers who participated in the PCH from 2019-2023. This evaluation utilized a combination of Medicaid claims and newborn data to evaluate programmatic outcomes. The analysis focused on two groups: Bexar County PCH participants who completed the program and their matched controls; and Bexar County PCH participants who used, but did not complete the program, and their matched controls.
Notable evaluation insights and findings include:
- From 2019-2023, the Bexar County PCH served a high proportion of high-risk mothers with maternal comorbidities, including obesity, substance use disorder, diabetes, asthma, and hypertension, with 64% of the clients being Hispanic/Latino.
- Among all Bexar County PCH participants, the administrative program data recorded that 76% received a social service referral, 35% received health education, and 32% received postpartum care.
- Mothers who completed the Bexar County PCH had more prenatal and postnatal visits, though this was not statistically significant compared to matched controls. Given the nature of the PCHI Model to coordinate care for participants, more encounters with the health care system are expected.
- Bexar County PCH participants who did not complete the program incurred significantly higher pharmacy costs than their matched controls.
The PCHI Model and Postpartum Care
The American College of Obstetricians and Gynecologists recognizes the importance of postpartum care by stating that “the weeks following birth are a critical period for a woman and her infant, setting the stage for long-term health and well-being.” In 2019, 36% of pregnancy-associated deaths in Texas occurred 43 days to one year postpartum, making a full year of continuous postpartum care one of the top recommendations of the Texas Department of State Health Services’ Maternal Mortality and Morbidity Review Committee.
With the passing of HB12, which increases pregnant people’s Medicaid coverage from 60-days to twelve months post-partum, there are now more opportunities for continued postpartum care. Many PCH sites in Texas are dedicated to serving pregnant individuals and mothers, making postpartum care a significant component of their services. Both studies found high rates of clients who kept their postpartum appointments ranging between 76 – 90%. This finding, as it relates to connecting women to postpartum care, is a major demonstration of the impacts that the PCHI Model can have throughout the state.
In summary, these early evaluations of the Pathways Community Hub Initiative in Texas highlight the significant role that coordinated, community-based care can play in connecting high-risk clients to essential health and social services. While completion rates may reflect local infrastructure challenges, the program’s ability to promote postpartum care, offer social service referrals, and engage parents and pregnant individuals in health education demonstrates its potential for improving maternal and infant health outcomes. Extended Medicaid coverage and ongoing commitment to postpartum support are key strategies for addressing persistent disparities and fostering long-term well-being for parents and their children throughout the state.
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