Foundational Partnerships: Community Hubs

To address the social health needs of high-risk medical and surgical patients, MSHIELD works closely with existing community “hub” programs in four geographic regions based on social service leadership initially implemented as Community Health Innovation Regions (CHIR) under the State Innovation Model and coordinated by the Center for Health and Research Transformation (CHRT). These hubs work to connect individuals with community-based organizations to meet social health needs. By working at the person, provider and systems levels, these programs will screen and refer patients, address social-related health needs, and ensure that community systems align to meet residents’ needs.

Each hub program provides an array of supportive social services to individuals who need safe and affordable housing, access to food, mental health and substance use services, complex care management, health education, assistance accessing care, transportation, utility needs, and other social and behavioral services.

The creation of a Community Health Integrated Network in Kent County envisions an evolution of the Health Net care model to include screening referrals from providers, community organizations, faith-based organizations, schools, government and others for all product lines and payers. Learn more here.

More than 50 organizations are working together in Jackson County to make sure there is no wrong door for residents to get their social and medical needs met. The Jackson Care Hub process leverages a ‘no wrong door’ model to identify patients with needs in physical and mental health, education, healthcare costs, safety, employment/income, housing, transportation, family care, literacy, utilities or food. The program provides more intensive support for patients requiring services from multiple community-based agencies, and who may benefit from working closely with a navigator. Learn more here.

MI Community Care (MICC) is based on a cross-agency, team-based approach to care coordination, built over several years to garner trust, strengthen relationships, and bridge historic siloes between medical, behavioral health, and social service providers. The MICC program in Livingston and Washtenaw Counties focuses on individuals who need long-term case management and services from multiple community-based agencies, and who may benefit from working closely with a CHW.

Genesee County Community Health Access Program (CHAP) focuses on individuals identified by healthcare providers, health plans, and community-based partner organizations that have a combination of unmet social determinant of health needs and a realized (or likelihood of) utilization of high cost, low value health care services that can be improved by engagement with a certified community health worker led cross-functional team. The established partnerships and Community Referral Network of the Greater Flint Health Coalition currently include more than 40 clinical healthcare providers and over 30 community and social service agencies. Learn more here.

The Center for Health and Research Transformation (CHRT) coordinates the Learning Network. CHRT facilitates dialogue between partners, manages data collection and analysis, supports internal and external communications, conducts community outreach, helps to secure additional funding, maintains fiduciary responsibilities, and both conducts and manages evaluations.

Collaborative Quality Initiatives (CQIs) which seek to address some of the most common, complex, and costly areas of surgical and medical care. CQI Coordinating Centers, led by University of Michigan faculty, work collaboratively with health care providers throughout Michigan to collect data to a centralized registry; analyze and share data to identify processes that lead to improved delivery of care and outcomes, and guide quality improvement interventions.

Value Partnerships is a collection of programs from Blue Cross Blue Shield of Michigan (BCBSM), physicians and hospitals across Michigan that make health care work better for everyone. Generous ongoing funding from Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) enables Michigan hospitals, physicians, and other health care providers to be involved in a unique, collaborative model using data collection and sharing of best practices to help health professionals improve patient outcomes.