Integrating health and social services is crucial for addressing the complex needs of individuals, particularly in underserved communities. By coordinating medical care with health-related social support services–such as housing, nutrition, and transportation–multiple Michigan initiatives aim to improve health outcomes and enhance the overall well-being of residents. These initiatives can provide valuable foundations, learning opportunities, and support to future efforts to create Michigan’s first Community Care Hub (CCH).
Regional Health Collaboratives in Michigan
One example of this approach in Michigan is the Regional Health Collaboratives (RHC). RHCs began as State Innovation Model (SIM) projects, and are now supported and partially funded by the Promotion of Health Equity (PHE) initiative which launched in 2020. With a 90/10 Medicaid health information technology and exchange match grant from the U.S. Centers for Medicare and Medicaid Services and the Michigan Department of Health and Human Services, PHE brings together projects that help communities better address social and clinical needs, improve health outcomes for Medicaid enrollees and other community members.
An RHC is a regional association of social service providers that collaborates to address the health-related social needs of Michigan residents with the goal of improving health and well-being. Association members often also include health care and behavioral health care providers. In their work, RHCs focus in particular on community-clinical partnerships, quality improvement, and technology and information exchange. RHCs in Michigan include:
- Health Net of West Michigan: Health Net of West Michigan connects individuals and families with healthcare and social services to address barriers to well-being. Through care coordination, navigation services, and community partnerships, Health Net helps residents access medical care, behavioral health services, transportation, food assistance, and other essential resources.
- Greater Flint Health Coalition: This nonprofit organization connects residents in Genesee County with critical programs that enhance health and well-being. By offering connections to medical care, mental health resources, career training, and other forms of support, the coalition addresses both health and health-related social needs to improve quality of life.
- Jackson Care Hub: Serving the Jackson community, the Jackson Care Hub is a secure web-based network that enables service agencies to coordinate care for residents. Providers across sectors such as healthcare, housing, transportation, and education use this system to identify local resources and refer clients directly to partner agencies, ensuring comprehensive support.
- MI Community Care: Among other initiatives, MiCC provides coordinated care to individuals with complex health and social needs in Washtenaw and Livingston Counties. By integrating services across healthcare providers and community organizations, MI Community Care aims to improve health outcomes and reduce unnecessary hospitalizations.
- Access Health: This initiative provides access to affordable, quality healthcare to Muskegon-area residents through their Access C3 Health Plan. Access Health also facilitates various local initiatives and programs focused on improving community health.
SDoH Hubs in Michigan
In 2024, Michigan also established Social Determinants of Health (SDOH) Hubs to further integrate health and social services. These hubs serve as regional coordination points that are made up of a) collaborating community members, health care professionals, social service providers, government partners, and business leaders and b) a backbone manager organization.
The purposes of SDOH Hubs are to develop and deliver locally-developed initiatives and programs that address health-related social needs. Current SDOH hub pilot sites include:
- Upper Peninsula: Chippewa County
- Northern Michigan: Northern Michigan Public Health Alliance
- West Michigan: Kent County
- East Central Michigan: United Way of Bay County; Saginaw County
- East Michigan: Greater Flint Health Coalition; Thumb Community Health Partnership
- Southwest Michigan: Berrien County
- Metro Detroit: Detroit Health Department; Wayne County Health, Human, and Veterans Services Department; United Way for Southeastern Michigan
Evolving towards a Community Care Hub model
RHCs and SDOH hubs both contain foundational elements of the Community Care Hub (CCH) model. The distinguishing factor of a CCH is their contracts with health payer partners to fund evidence-based social service programs.
“Michigan is still limited in that there isn’t a formal CCH in our state,” says Deana Smith, manager of strategic initiatives at CHRT. “However, there is a lot of activity in Michigan that is building momentum towards CCH-like entities, including the RHC and SDOH hub collaboratives. At the WHI, we want to pull from that learning and momentum to lead our community forward towards a CCH model, as other organizations across the country have done.”
Collectively, these initiatives highlight the extensive and varied efforts across Michigan to integrate health and social services. By fostering collaboration at both local and state levels, Michigan demonstrates that such integration is feasible and provides the foundational elements that make implementing formal CCH models possible in our near future.