The Community Health Workers (CHWs), identified, hired and trained directly within the community, serve as the foundation to our effort to change basic health and social outcomes. The Community Health Access Project (CHAP) provides a recognized model of community-based care coordination as a means of improving the basic health and social outcomes of individuals in neighborhoods with the greatest needs.

The Pathways Community HUB is a national model of outcome focused, pay for performance, home visiting style care coordination.  The focus is to reach those at greatest risk, identify and address all health, social and behavioral health risk factors.  Improved outcomes and reduced cost have been demonstrated.  The Community HUB serves as the center of a community wide network of care coordination agencies that employ the Community Health Workers who provide the care coordination service.  More information regarding the model is available at AHRQ Quick Start Guide.

Community Empowerment

In this model of Community Care Coordination, an individual from within the community served provides a culturally relevant link to existing health and social services. Employment, college training, and support services are provided to the Community Care Coordinator so that the community and its residents become the agents for change.

Social Advocacy

Community Health Workers open the door for necessary services to reach clients, who are otherwise isolated due to cultural, geographic and economic barriers. Care coordination services do not duplicate, but facilitate and strengthen existing community resources. Through home visits, the Care Coordinator serves as an ongoing resource to neighborhood families, identifying individual needs and providing connections to appropriate services.

Client Responsiveness

Trained at the college level, Community Health Workers collect specific health and social information, which is transferred immediately for review by health professionals. Working with the CHAP nurse and physician, the Community Health Workers assists clients by accessing health care services quickly and in most cases through a primary care provider. Most importantly, the Community Health Worker helps recognize potential problems and supports continued patient compliance, thus preventing poor outcomes.

Proven Model

CHAP is modeled after the Alaska Community Health Aide Program, which began over 40 years ago and is credited with substantially improving that state’s poor social and health statistics. With over 500 aides serving isolated areas, Alaska now has one of the lowest low birth weight rates in the United States.  CHAP participated with the Ohio Department of Health, Ohio State University and the Centers for Disease Control in a recent study documenting LBW improvement and cost savings using the Pathways Model.


To eliminate health and social disparities in our community by finding those at risk, connecting them to care, and measuring the outcomes.  We believe all communities can be transformed through the work of community health workers and the creation of community HUBs – an accountable care coordination delivery system.