SIM Community Care Coordination Intervention

Enhanced care coordination is being implemented in the follow ways:

• Twelve (12) social service and clinical service agencies in the community are working together to enroll residents of Livingston and Washtenaw counties who are eligible for the intervention to participate in enhanced care coordination.
• Eligible residents are identified through provider referrals as well as through a computer assessment of a resident’s predicted eligibility.
• The agencies are using a shared IT platform where each agency can exchange information and communicate with one another to better coordinate care.
• A shared assessment tool used among the agencies helps to identify social needs of each participant and a shared care plan helps agencies work together along with the participant to set and achieve goals to address their needs.
• Three (3) community health workers have been hired to work across the 12 agencies to provide additional assistance to participants enrolled in enhanced care coordination.

(please click on the images below to view larger)

The participating social service and clinical service agencies are:

Avalon Housing (
The Corner Health Center (
Home of New Vision (
Jewish Family Services of Washtenaw County (
Livingston Catholic Charities (
Livingston County CMH (
Michigan Medicine Complex Care (
Packard Health (
St. Joe Complex Care (
Washtenaw County CMH (
Washtenaw Health Plan (

If you are a health care or social service provider wishing to make a referral, please use the form provided here: SIM Referral Form

For more information about the Community Care Coordination Intervention, please contact Jeremy Lapedis at