Collaborating with community and clinical partners to close the gap between healthcare and social service systems across the state.
Clinical care accounts for just 20% of patients’ health outcomes but represents the overwhelming majority of health care spending. Addressing Social Determinants of Health requires systems-level change—together we can build a bridge to better health.
MSHIELD partners with organizations across Michigan doing the work to build healthier communities. As a partnering Collaborative Quality Initiative (CQI), we connect community organizations with other CQIs and their participating healthcare providers to address social health needs and link patients to local resources for food insecurity, housing instability, transportation, and more.
There is a growing evidence base showing that interventions addressing patients' social health needs are associated with better health outcomes, lower costs, or both. MSHIELD supports CQIs to expand these interventions to specialty care settings. Our work is intentionally community-driven and co-developed. We bring together community hubs, CQIs, and clinicians to screen patients for social health needs, link them to resources, and collect data to assess clinical outcomes and improve practices.
MSHIELD supports our partners through every stage of implementing closed-loop social needs screening and referral:
Based on community-identified priorities, MSHIELD convenes the community hub, CQI, and specialty care clinic in preparation for implementing social needs screening and referral
Clinic screens patients for social health needs like food, housing, and transportation
Clinic refers patients with social health needs directly to the community hub
Community hub connects patients to resources and coordinates services
Community hub closes the referral loop and provides feedback on the outcome of the referral to the clinic, CQI, and MSHIELD
MSHIELD conducts process evaluation; partners collect data to assess whether clinical outcomes vary by unmet social health needs
To address patients’ social health needs, MSHIELD works closely with community hubs across Michigan that provide care coordination services, connect patients to community resources, build community capacity to address health inequities, and drive improvements in population health.
Our Impact: Early Success in Genesee County
Along with the Michigan Bariatric Surgery Collaborative and local partners, MSHIELD built a referral pathway to resources for bariatric surgery patients. Patients are screened for social health needs at the McLaren Flint Bariatric and Metabolic Institute and referred to the Mid-Michigan Community Health Access Program where case managers connect them to resources and services.
In Their Own Words
Hear what our partners are saying about us!