State Innovation Model (SIM)

Connecting people to social services to improve health and reduce preventable emergency department use.

Social determinants are increasingly recognized as playing an important role in health outcomes. Social and environmental factors account for 50%-60% of health outcomes, while clinical care accounts for only 10%-20% of health outcomes (Schroeder, S.A. (2007). We can do better- improving the health of the American people. NEJM 357: 1221-8).

 

SIM in Livingston and Washtenaw Counties

Enhancing care coordination and addressing social determinants of health in Livingston and Washtenaw counties

The Livingston and Washtenaw counties region is engaging in two complementary efforts to integrate social services with medical care:

Community Care Coordination Intervention

The goal of the Community Care Coordination Intervention is to reduce and prevent high-utilization of the emergency department by addressing social needs through enhanced care coordination.

Go to SIM Community Care Coordination Intervention page

Primary Care-Based Social Services Screening, Referral, and Connections

The goal of the Primary Care-Based Social Services Screening, Referral, and Connections is to identify social needs among primary care patients and connect patients through referrals to resources to address their needs.

Go to SIM PCMH Initiative page