Food insecurity, literacy, housing, transportation. These non-medical needs, and many others, can have a significant impact on health. By addressing these factors–known as the social determinants of health–we can improve the health of individuals while diminishing troubling health disparities.
In the fall of 2015, the Washtenaw Health Initiative secured funding from the Michigan Department of Health and Human Services to launch a three-year pilot, part of Michigan’s State Innovation Model efforts, to diminish emergency department utilization while addressing the social determinants of health in Livingston and Washtenaw Counties.
In 2020, the regional collaborative was renamed MI Community Care (MiCC) and other innovations were introduced, including efforts to refine the care coordination model, to improve the local and state health care system, and to scale up the work. Currently, MiCC’s goals are:
- To provide holistic, coordinated, patient-centered care to people with complex lives and conditions;
- To support regional health, mental health, and social service providers; and
- To enhance the local and state care delivery system.
Physician practices in the area screen for social needs and offer program referrals to those who are willing to accept assistance.
In the MiCC collaborative, one health or social service organization serves as the “lead” for each individual enrolled in the program. A care coordinator or community health worker at the lead organization works with participants to identify their health and personal goals, and coordinates with partner organizations to help participants meet those goals.
As the backbone organization to the Washtenaw Health Initiative, the Center for Health and Research Transformation (CHRT) works with MiCC partner agencies in the region to address the medical and social needs of frequent utilizers of emergency department services in a coordinated way.