The PCHI® Model helps communities build a transformative and sustainable community-based care coordination network. Community health workers (CHWs) were the reason the Model was originally designed. CHWs are uniquely able to engage community residents at risk for poor health and social outcomes. The PCHI Model provides training and tools for CHWs to identify risk factors and work towards eliminating those risks one by one. The model provides the infrastructure to track risk factors from identification through mitigation and link payment directly to outcomes. The PCHI Model is a quality improvement framework for communities to build their own robust network of community-based care coordination in partnership with local stakeholders to align resources and achieve positive outcomes.