Doctor and Patient

Final recommendations in the following areas have been adopted by the steering committee for current and future implementation strategies, pilot programs and planning efforts in the following topical areas:

  • Primary Care Capacity and Safety Net Clinic Coordination
  • Community Coordination and Dental Services
  • Medicaid and Marketplace Outreach and Enrollment
  • Mental Health and Substance Use Disorder Care
  • State Innovation Model

Primary Care Work Group
1. Safety Net Clinic Coordination: Explore and implement ways for community clinics to leverage resources and work together to better serve the priority population.

Mental Health and Substance Use Disorder Care Work Group
2. Opioid ProjectCoordinate organizations and providers to address the opioid epidemic on the individual, community, and policy levels
3. Frequent Users Systems Engagement: Reduce emergency room visits of homeless residents
4. Tailored Mental Health Management Support (TaMMS): Incorporate a behavioral health resource to support primary care physicians and improve access to mental health care in safety net settings.

Community Coordination and Dental Services Work Group
5. VA Voluntary Respite Program: 
Connect VA volunteers with veterans providing care for other family members
6. Information for Navigating Senior Services:  Assess how seniors and their caregivers access community resources and identify potential areas for improvement, if possible
7. Advance Care Planning Project: Disseminate and evaluate the use of the advance care planning conversation guide created by this group
8. Single  Community Health Assessment and Implementation Plan: Align nonprofit hospitals’ Community Health Needs Assessments and Implementation Plans to create a single plan for all hospitals.
9. Care Net – Care Management Coordination: Implement a pilot program to improve coordinated care for patients in safety net settings.

Medicaid and Marketplace Outreach and Enrollment Work Group
10. Outreach & Enrollment Coordination: Educate uninsured residents of Washtenaw County about their options for health care coverage using the Health Insurance Marketplace or enrolling in the Healthy Michigan Plan. Coordinate the training and technical assistance of those conducting enrollment in new health care coverage options. 
11. Community Outreach & Educationin development in early 2018

State Innovation Model Work Group 
The Livingston Washtenaw SIM has two main components in our community: Community Care Coordination intervention and Patient Centered Medical Home social needs screening and referrals.
12. Medicaid Health Plan Coordination: Coordinate the work of SIM and health plan care managers
13. Livingston Implementation: Engage Livingston partners to continuously improve the implementation of the Community Care Coordination intervention
14. Clinical PCMH/ASC: Coordinate regional SIM activities with the work of SIM-recognized patient centered medical homes within the Livingston Washtenaw region
15. Hublet Coordination: Continuously improve the Community Care Coordination intervention and online care management platform, untangle complex issues facing CCC participants, and monitor referrals among hublets and other community-based services

Complete projects

Detox Protocol: Create a streamlined process for referral to medically-supported detoxification services.

Reduced Fee Dental Initiative: Work with community dentists on a reduced fee referral program for low-income adults.

Blue Cross Complete Pilot / Connecting New Medicaid Enrollees with Primary Care Physicians and Community Resources: Use Community Health Advocates trained by the Washtenaw County Public Health Department to connect new Blue Cross Complete Medicaid members to primary care providers at Packard Health, and to other needed community resources

Dental Acute Care Pilot: Add additional providers and hours to the Community Dental Center to increase access to acute dental care for patients with abscesses that are referred from area emergency departments.

Medicaid Enrollment Partnership with DHS: Locate a Department of Human Services (DHS) workers at the Washtenaw Health Plan to facilitate Medicaid enrollment. Partner with the United Way of Washtenaw County to locate three Community Resource Navigator AmeriCorps members at area agencies to assist with benefits enrollment.

Primary Care Capacity: Analyze and expand primary care access for WHI target populations by working with the local health systems and safety net providers.