Low back pain (LBP) continues to be a challenging condition to manage effectively. Recent guideline recommendations stress providing non-pharmacological care early, limiting diagnostic testing, and reducing exposure to opioid pain medications. However, there has been little uptake of these guideline recommendations by providers, patients or health systems, resulting in care that is neither effective nor safe. This paper describes the framework for an evidence-based pathway that would transform service delivery for LBP in the United States by creating changes that facilitate the delivery of guideline adherent care. An evidence informed clinical service pathway would be intentionally structured to include; a) direct linkages to community and population based resources that facilitate self-management, b) foundational LBP care that is appropriate for all seeking care, c) individualized LBP care for those who have persistent symptoms, and d) specialized LBP care for instances when advanced diagnostics and intensive treatments are indicated. There is an urgent need to transform LBP care by optimizing clinical care pathways focused on multiple opportunities for non-pharmacological treatments, carefully considering escalation of care, and facilitating self-management. Such approaches have the potential to increase patient access to guideline adherent LBP care as an alternative to opioids, unwarranted diagnostic tests, and unnecessary surgery.