The Livingston and Washtenaw County Community Health Innovation Region, with funding from the Michigan Department of Health and Human Services, works to provide patient-centered, coordinated care to frequent utilizers of emergency department services.
This pilot program was built on the strength of community partners. Staff from one dozen health and human service organizations, including housing providers, substance use counselors, and health clinics, were intimately involved in designing the intervention model.
Today, three-dozen care coordinators who work for these health and human service organizations–in conjunction with three full-time community health workers who have been hired to assist with the pilot–are coordinating care for participants and helping to refine the model based on the lessons they have learned since implementation.