This care coordination program, developed by Drs. Sarah and Mark Redding at the Pathways Community Hub Institute in Ohio, is based on more than 20 years of evidence gathered through collaboration with community health workers (CHWs).

Adapted by Elevate Health to help Pierce County residents, the Pathways Community HUB trains CHWs to help people navigate health and social service systems. Together, the two select and follow customizable plans of action (called pathways) to eliminate the individual’s barriers to health care.

Elevate Health’s Pathways program is the first and only PCHI certified program of its kind in Washington. It is also one of our central care coordination services. It shares that distinction with two other programs, the Community Health Action Team and Health Homes. Together, the three services form Elevate Health’s Care Continuum Network.

A person’s circumstances affect their ability to stay healthy or receive good care. These circumstances — including employment status, or access to food, among others — are called the social determinants of health. Sometimes, social determinants become barriers to being healthy and accessing health care. Commonly, these barriers include:

Poverty and unemployment
Language barriers
Mental health challenges and substance use
Lack of housing and/or food
Transportation challenges
Domestic violence

Pathways serves as a bridge between the two. When an individual and community health worker (CHW) begin their work together, they evaluate the social determinants that act as barriers to the individual’s health. Each barrier is assigned a pathway, after which the individual and the CHW work together to complete it. In this process, the CHW — in mentoring, in making referrals to food banks and other organizations, in supporting good medical care — helps an individual navigate the worlds of health services and social services.

We work with several organizations to conduct Pathways. Our partners include health care providers, government agencies and community-based organizations, among others.

They each maintain a bidirectional relationship with Elevate Health and employ trained community health workers (CHWs) who provide knowledgeable, culturally appropriate care, receive referrals generated through the program, and make referrals generated by their respective agencies to Pathways.

Please evaluate whether your friend is having medical or behavioral health emergency.

If you or someone you know if suffering a life-threatening medical or behavioral health emergency, please call 9-1-1 for immediate assistance.

If you or someone you know is experiencing a non-life-threatening but urgent mental health crisis, call one of the following 24/7 Crisis Lines:

Pierce County Crisis Line: 800-576-7764

National Suicide Prevention Lifeline: 1-800-273-8255

Crisis call lines available 24/7:

Pierce County Crisis Line: 800-576-7764

National Suicide Prevention Lifeline: 1-800-273-8255

If your friend needs non-emergent help, please contact us at care@elevatehealth.org. We’re happy to make referrals for care coordination services to our partners, listed above.

Pathways Community HUB at Elevate Health isn’t simply another player in the health care field. Our goal is to improve the field, to make health care more person-focused, equitable, and cost-effective. Importantly, Pathways is also creating a valuable and long overdue bridge between the fields of medicine and social services, which work together to effectively support a person’s health and well-being.

Frequently Asked Questions

Pathways Community HUB

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