Promoting health equity starts with partnership.
Clinical care accounts for just 20% of patients’ health outcomes but represents the overwhelming majority of health care spending. We can do better.
Addressing Social Determinants of Health requires systems-level change; no single entity is equipped to eliminate health inequities. MSHIELD collaborates with community and clinical partners to close the gap between healthcare and social service systems across the state. Together we can build a bridge to better health.
MSHIELD partners with transformative 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 social determinants of health are associated with better health outcomes, lower costs, or both. Using the following workflow as a guide, MSHIELD supports other CQIs and their participating healthcare providers to screen patients for social health needs, link them to resources, and collect data to assess clinical outcomes and improve practices.
Based on community-identified priorities, MSHIELD convenes the community hub, CQI, and specialty care clinic in preparation for piloting closed-loop social needs screening and referral
Clinic screens patients for social health needs
Clinic refers patients with social health needs directly to the community hub
Community hub completes intake process, connects patient 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 overall process evaluation; partners collect data to assess whether clinical outcomes vary by unmet social health needs
To address patients’ complex social health needs, MSHIELD works closely with community hubs 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 services.