About Us
Southern Nevada Pathways Community HUB
Working Together for a Healthier Clark County: An Evidence-Based Care Network
About Us
Southern Nevada Pathways Community HUB
Working Together for a Healthier Clark County: An Evidence-Based Care Network
About the SNV HUB
The Southern Nevada Pathways Community HUB (SNV HUB) is a collaborative approach to identifying risk, streamlining referrals, reducing service duplication and enhancing care systems in Clark County, Nevada. The SNV HUB creates a safety net for groups experiencing disproportionate impact and is the only Pathways Community HUB in Southern Nevada.
The SNV HUB contracts with local care coordination agencies (CCAs) who employ community health workers (CHWs) to work with community members. The CHWs are trained, certified, and provided with ongoing support from the SNV HUB. CHWs trained by and operating under the SNV HUB are eligible to receive CHW I certification from the Nevada Certification Board.
Participants from the community are matched culturally and linguistically with CHWs who coordinate care and facilitate access to community resources. The SNV HUB is uniquely positioned to address priority needs in Southern Nevada relative to access to care, substance use disorder and access to health insurance coverage. CHWs provide intensive care coordination to participants, ensuring individuals and their families receive necessary services to address their needs and overcome barriers such as transportation, childcare, and agency referrals. CHWs work with community members at greatest risk, identify individually modifiable risks using 21 Standard Pathways from the Pathways Community HUB Institute® (PCHI®) to track risk mitigation.
The SNV HUB has achieved full national certification from the Pathways Community HUB Institute®. This is a testament to the rigorous standards and proven effectiveness of our approach.
Pathways Community HUB Institute® Model
The SNV HUB follows and is certified in the Pathways Community HUB Institute® Model (PCHI® Model), a proven framework for community-based care coordination. The PCHI Model is an evidence-based approach to address social factors that affect health and is proven to mitigate multiple disparities by building a sustainable community-based care coordination network that addresses modifiable risk factors and fosters connection to medical, social, and behavioral and mental health services.
This model expands the delivery system to include community-based CHWs and uses an outcome-oriented framework. The PCHI Model enables the SNV HUB to provide the necessary infrastructure to support the expansion of the health care delivery system.
The PCHI Model and SNV HUB: A Community Solution
The PCHI Model is based on continuous quality improvement. Quality improvement is integrated into ongoing operations to ensure fidelity to the PCHI Model, advance work toward health care equity, and improve participant outcomes.
© Pathways Community HUB Institute® 2025
About Pathways
Pathways are tools used by CHWs to identify and track individually modifiable risk factors. A Pathway is closed as completed when a measurable outcome, which is meaningful to the participant, is achieved. If an outcome is not reached, then a Pathway is closed as partially complete and the CHW’s efforts to resolve the risk are recorded for evaluation.
Everyone in the HUB network is trained to use the PCHI Model to collect data in a systematic way, including data collection tools, Standard Pathways to track risk factors, and templated reports. The data that are gathered is presented to the Pathways Community Advisory Council for review and action.
Statement of Need
In Clark County there is a growing need for non-medical, health-related social care services among health care and community-based organizations; yet the supply of such services remains limited and siloed. Current efforts to address these challenges are often fragmented and lack coordination. The existing system of care for individuals with complex needs is often inefficient and ineffective, leading to poor health outcomes and increased health care costs.
Efforts by community information exchanges and other entities to coordinate identification of services and facilitate closed-loop referrals do not solve the limited supply and can exacerbate the shortfall by directing additional potential clients and requiring new workflows of community-based organizations (CBOs) without additional financial resources and technical assistance.
While there are an increasing number of CBOs partnering with health plans and health systems to provide health-related social care, intentional effort is needed to scale capacity and necessary infrastructure to close care gaps and support people using a “whole-person approach.” Many CBOs in Clark County do not have the resources and infrastructure to contract directly with managed care organizations and other insurance companies to meet the needs of Clark County residents.
The SNV HUB advances a sustainable, equitable, and scalable model for organizing CBOs into a coordinated local network of services for community members. The SNV HUB offers a range of services, infrastructure, and data capacity that allow for broader participation of CBOs in social care delivery that is paid for by health plans and health systems.
A Neutral, Transparent and Accountable Entity
As a neutral entity, the SNV HUB is the quality center of the network and strives to:
- Contract with CCAs and referral partners
- Contract with payers and establish reimbursement
- Ensure a collaborative approach to risk identification
- Streamline referrals by coordinating referral partners, CCAs, and participants
- Convene the Pathways Community Advisory Council
The SNV HUB brings together diverse local partners, creating a network to address the health-related social needs of community members placed at higher risk for poor health outcomes. Among these partners are community-based organizations, health systems, health plans and government agencies.
The SNV HUB uses an outcomes-oriented framework for identifying and mitigating health-related social needs. Outcome criteria for each Pathway are defined within the PCHI Model, and Pathways remain open until a participant’s need is met according to the outcome criteria.
A structured care coordination agency network is created through the SNV HUB by contracting with CCAs. CCAs are provided with ongoing training and support and are certified to serve clients referred to the SNV HUB. CCAs employ the CHWs who implement the PCHI Model and serve the community.
Referrals are streamlined and coordinated across agencies to ensure a ”no wrong door” approach to services. The SNV HUB works with a wide range of referral partners, including:
- Community-based organizations
- Social service organizations
- Faith-based organizations
- Health plans
- Health care practices
- Health systems
- Local and state government agencies
The approach to screening and data collection is standardized to support monitoring of risk factor mitigation and bidirectional communication.
The SNV HUB Team
Alex Sanchez
Data Analyst
Ally Schenck
Evaluator
Ambyr Leigh
IMHS Project Manager
Amy Schmidt
IMHS Director
Gina Pirozzi
Community Outreach and Referral Coordinator
Jerry Reeves
Medical Director
Kandrea Higgins
Director
Nicole Taylor
Quality Improvement Advisor
Regina Neal
Quality Improvement Coach
Sabria Davis
Referral Coordinator
Trei Herd
Marketing and Engagement Manager
Alex Sanchez
Data Analyst
Ally Schenck
Evaluator
Ambyr Leigh
IMHS Project Manager
Amy Schmidt
IMHS Director
Gina Pirozzi
Community Outreach and Referral Coordinator
Jerry Reeves
Medical Director
Kandrea Higgins
Director
Nicole Taylor
Quality Improvement Advisor
Regina Neal
Quality Improvement Coach
Sabria Davis
Referral Coordinator
Trei Herd
Marketing and Engagement Manager