Omaha Pathways Community HUB

The Omaha Pathways Community HUB (HUB), an initiative of the Omaha Community Foundation, is working to improve the health of everyone in our community. The HUB works side by side with healthcare providers and local organizations to make sure people have access to the resources they need and deserve to be healthy and thrive. Our team meets people where they are, connecting them to services and support that care for the whole person—not just their medical needs. The Pathways HUB model is evidence-based with proven success and impact.

Launching the HUB

Starting in 2021, more than 12 local and regional organizations across the healthcare, public health, and social service sectors, explored the PCHI® model and jointly decided to bring a Pathways Community HUB to Omaha. Their vision was to explore how this innovative model could improve outcomes and create a better system of care for our community. The Omaha HUB officially launched services in 2024, focused on serving pregnant and postpartum women and their families. With the current goal of improved birth outcomes and healthier families, the HUB will aim to expand services for other groups experiencing barriers to health in the future.

Following the Pathways Community HUB Institute® model, the certified Omaha HUB is developing a sustainable network of Community Health Workers — trained frontline public health workers who have a deep understanding of and connection to the community. The HUB contracts with agencies that employ Community Health Workers, who connect with community members experiencing barriers to medical, behavioral, and social care. The CHWs partner with program participants to remove these barriers, improve access to care, and achieve their health and wellness goals.

SEE OUR PROGRESS

An Innovative Model

The PCHI® Model is a nationally recognized, proven model that reduces the risk factors that drive poor outcomes, improves health outcomes, and demonstrates a return on investment. The local program is part of a national, evidence-based, initiative to create care coordination networks that serve under-resourced residents. The Pathways HUB Model is in use in more than 40 communities across the United States. These communities have seen firsthand the impact that a community-designed care coordination network has on individuals and their families.

Key Model Components:

• Community Health Workers, reflective of the community they serve, meet people where they are – in their homes, community, or clinic.
• The holistic model addresses resources we all need – and deserve – to be healthy and thrive (See 21 Pathways below).
• Standardized tools and workflows support the team to track risk factors from identification through resolution and link payments directly to outcomes.
• A community-driven, quality improvement framework ensures we are meeting community needs, delivering high-quality services, and achieving outcomes.
• A return on investment has been shown by established HUBs in other communities. The Community Health Access Project, for example, reported a 60% reduction in low birth weight births for participants and a $5.59 return for every $1 invested in Pathways HUB model.

21 Evidence-based Pathways

Pathways are tools used by Community Health Workers to identify and track participants needs. A Pathway is closed when a measurable outcome, which is meaningful to the participant, is achieved. Financial sustainability is vital for community-based organizations and the community health worker workforce. With the PCHI Model, Pathways Community HUBs and Pathways Agencies can be reimbursed as they complete Pathways with their residents.

1. Adult Education
2. Developmental Referral
3. Employment
4. Family Planning
5. Food Security
6. Health Coverage
7. Housing
8. Immunization Referral
9. Learning
10. Medical Home
11. Medical Referral
12. Medical Adherence
13. Medical Reconciliation
14. Medical Screening
15. Mental Health
16. Oral Health
17. Postpartum
18. Pregnancy
19. Social Service Referral
20. Substance Use
21. Transportation

Improving Birth Outcomes

The HUB is initially focused on addressing unfair differences in outcomes among pregnant and postpartum individuals in our community. We know that barriers to medical and social services — such as insurance coverage, transportation, and stable housing — are all risks to a healthy birth.

In Omaha, race and geography play an outsized role in pregnancy outcomes. Black individuals experience significantly higher rates of preterm birth, and Black infants have a higher mortality rate in the first year of life than infants of other races. We also see higher rates of poor outcomes in certain areas of our community where there are higher barriers to healthcare, increased levels of poverty, and lower levels of healthcare coverage. The HUB emphasizes serving folks living east of 72nd street as a community needs index identified this group as facing the most barriers to healthy pregnancy outcomes. The HUB also serves any high-risk pregnant women or individuals who have been referred.

PATHWAYS HUB PREGNANCY ASSISTANCE

Become a Referral Partner

If your organization or agency works with pregnant individuals who might be a good fit for Omaha Pathways Community HUB services, consider becoming a Referral Partner. To learn more, please call 402-884-8493 or email pathwayshub@omahafoundation.org.

MAKE A REFERRAL

Funding Partners

CHI Health, Healthy Blue Nebraska, Nebraska Total Care and UnitedHealthcare all provided funds to launch the Pathways Community HUB as part of their missions to help improve the health of Nebraskans.

Donate to the Omaha Pathways Community HUB to help us create a healthier community.