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Omaha Pathways Community HUB

Coordinating care for a healthier community

The Omaha Pathways Community HUB is creating a network of Care Coordination Agencies and Community Health Workers focused on removing barriers to optimal health.


The Omaha Community Foundation launched the Omaha Pathways Community HUB in 2023. The local program is part of a national initiative to create care coordination networks to serve under-resourced residents.

Following the Pathways Community HUB Institute® model, the Omaha Community Foundation 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 identify at-risk individuals and connect them with medical, behavioral, and social services to remove barriers to health. The initial phase of the program focuses on addressing health disparities among pregnant and postpartum individuals at greatest risk for poor birth outcomes.

The PCHI Model provides training and tools for Community Health Workers to identify risk factors and work toward eliminating those risks one by one. The Omaha Pathways Community HUB provides the infrastructure to track risk factors from identification through resolution and link payments directly to outcomes.

21 Evidence-based Pathways

Pathways are tools used by Community Health Workers to identify and track individually modifiable risk factors. 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 initial phase of the program focuses on addressing health disparities among pregnant and postpartum individuals at greatest risk for poor birth outcomes. 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. The HUB emphasizes serving Black pregnant women and their families with high risk factors, living east of 72nd Street. 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.


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 email


Funding Partners

CHI Health, Healthy Blue Nebraska, Nebraska Total Care and United Healthcare 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.

Return on Investments

The Pathways HUB Model is in use in more than 35 communities across the United States. These communities have seen first hand the impact that a community-designed care coordination network has on individuals and their families.

The Community Health Access Project, the Pathways HUB for six counties in Ohio, reported a 60% reduction in low birth weight births for participants, and a $5.59 return for every $1 invested in Pathways HUB model.

Questions? Please contact us!
Kelly Nielsen

Director of Omaha Pathways Community HUB

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