UniteWI, Inc., a Pathways Community HUB, (UniteWI) has been initiated to significantly improve social and health outcomes through reducing social risks in Milwaukee. UniteWI aims to expand and extend its services and reach to communities in the surrounding counties in order to address overall health disparities, improve population health, and reduce excess rates of infant death. The project will address this overall disparity by ensuring care coordination services are available to address the social and health needs of the population. The HUB infrastructure provides tools and strategies needed to ensure that at-risk individuals in a community are served in a timely, coordinated manner, and utilizes a trained and expanding community health worker (CHW) workforce to do so. The HUB ensures that persons and populations within the region it serves are connected to meaningful health and social services that contribute to positive health outcomes. The HUB will help to avoid duplication of effort in care coordination and keep individuals from falling through the cracks. Finally, UniteWI will assure the ongoing success of the model by aligning payment with outcomes, rather than services, and securing ongoing third-party payer support via gathered information and demonstrated Return on Investment (ROI). Those three overarching principles to guide UniteWI efforts are, as outlined below: • Find: Identify those at greatest risk • Treat: Ensure that individuals receive evidence-based health and social services. • Measure: Document and evaluate benchmarks and final outcomes. To accomplish its goals, the UniteWI HUB provides centralized processes, systems, and resources. These allow for systematic tracking of those being served and incentive payments to milestones that are tied to the improve the community member’s health and well-being.