Information for
Health Care Teams and Community-Based Organizations
Partnering with the SNV HUB as a care coordination agency or referral partner improves health outcomes for patients and clients.
Information for
Health Care Teams and Community-Based Organizations
Partnering with the SNV HUB as a care coordination agency or referral partner improves health outcomes for patients and clients.
Care Coordination Agencies
Our care coordination agency partners (CCAs) are the backbone of the Southern Nevada Pathways Community HUB (SNV HUB). Utilizing an in-home or community-based visit model, with a strong emphasis on in-home visits, the CCAs employ community health workers (CHWs) who match cultural and linguistic backgrounds to reach out to individuals at higher risk of negative health outcomes related to pregnancy, chronic disease, and behavioral health, identify risk factors and barriers, and foster connections to medical, social, and behavioral health services.
Participating Care Coordination Agencies
- Dignity Health
- Nevada Health Centers
- Southern Nevada Health District
Referral Partners
We work with a wide range of referral partners, including:
- Community-Based Organizations
- Social Service Organizations
- Faith-Based Organizations
- Health Care Practices
- Health Systems
- Health Plans
- Local and State Government Agencies
Referring clients to the SNV HUB ensures that the populations of focus are provided with personalized support by an assigned CHW. Using the evidence-based PCHI Model, the CHW works with clients to address medical, social and behavioral health needs while using a whole-person approach. Connecting clients to the SNV HUB care coordination network lessens the burden on community agencies to provide complete services and removes the silos often created in health care systems.
The SNV HUB streamlines and coordinates referrals across agencies to ensure a “no wrong door” to services. We use a standard approach to screening and data collection to support monitoring of risk factor mitigation and bidirectional communication.
SNV HUB Participant Testimonial
The motive of this letter is to express how sincerely grateful I am for the help this program has offered. [My CHW] has helped me overcome the difficulties and struggles I was facing. Her help and compassion has been essential to me. She was always willing to provide me with different resources such as food, transportation, schooling, hospitals, and dentists. I would like to refer everyone to this program, especially all the women who have needs like mine.
-Yadira G., SNV HUB Participant
SNV HUB Participant Testimonial
The motive of this letter is to express how sincerely grateful I am for the help this program has offered. [My CHW] has helped me overcome the difficulties and struggles I was facing. Her help and compassion has been essential to me. She was always willing to provide me with different resources such as food, transportation, schooling, hospitals, and dentists. I would like to refer everyone to this program, especially all the women who have needs like mine.
-Yadira G., SNV HUB Participant
SNV HUB Participant Testimonial
The motive of this letter is to express how sincerely grateful I am for the help this program has offered. [My CHW] has helped me overcome the difficulties and struggles I was facing. Her help and compassion has been essential to me. She was always willing to provide me with different resources such as food, transportation, schooling, hospitals, and dentists. I would like to refer everyone to this program, especially all the women who have needs like mine.
-Yadira G., SNV HUB Participant
FAQs for Health Care Teams and CBOs
The SNV HUB:
- Pairs community members with certified CHWs trained in the Pathways Community HUB Institute® Model (PCHI Model) who meet regularly with clients, build relationships, and assess needs and risks based on 21 Standard Pathways. CHWs help clients develop a personalized care plan based on identified risks and needs and use Pathways Learning Modules to help clients learn how they can improve their health.
- 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.
- Has established a care-coordination network in Clark County to streamline and coordinate referrals across agencies to ensure a “no wrong door” to services.
- Uses a standard approach to screening and data collection to support monitoring of risk factor mitigation and bidirectional communication.
The two primary ways to partner with the SNV HUB are:
- As a care coordination agency with community health workers to serve clients.
- As a referral partner to send clients to be served by a CHW.
Organizations best suited for SNV HUB partnership include:
- Organizations with a community health worker team
- Social service organizations
- Community agencies
- Faith-based organizations
- Health care systems and clinics
- Health plans
- Health departments
- Local and state government agencies
©Pathways Community HUB Institute® 2025