The UniteMke work is based on the national Pathways Community HUB Model and happens in three simple steps. First, find those who are at risk. Second, treat the "whole" person with evidence based care and lastly, measure the outcomes with simple push button reports from cutting-edge software! The Community Pathways model utilizes best practices, payment-for-outcomes process and services that successfully identify, treat, and measure for families in at-risk neighborhoods. The process and the software are unparalleled in the community health industry. While Milwaukee is one of 35 cities implementing Care Coordinations System, Milwaukee is the first city to provide medical assessments and reconciliation by direct connection to pharmacies, and the first to offer an asthma focused initiative.