The Livingston/Washtenaw County care coordination pilot is a highly collaborative project, developed with more than a dozen health and human service organizations that serve vulnerable populations across the region.

Founding partners

Staff from 12 health and human service organizations built the model from the ground up; coordinate care for the participants engaged in the pilot; and are finding ways to refine the model based on the lessons they have learned since implementation. These founding partners are:

  • Avalon Housing builds healthy, safe and inclusive supportive housing communities as a long-term solution to homelessness in Washtenaw County
  • Corner Health Center provides judgement-free, high-quality, affordable health services to young people aged 12 through 25 in Washtenaw County
  • Home of New Vision provides treatment services and recovery supports to help people struggling with substance use disorders find a better way of life
  • IHA provides personalized, health and medical services to patients with an eye toward patient satisfaction with clinical quality, services, accessibility, and value
  • Jewish Family Services of Washtenaw County provides programs and services ranging from older adult caregiving to immigrant resettlement and career services
  • Livingston County Catholic Charities provides a range of human services including volunteer caregivers for seniors, individual and group counseling for those with mental health and substance use disorders, and more
  • Livingston County Community Mental Health provides a range of services–from respite care to community-supported living–for individuals living with mental health and substance use disorders
  • Michigan Medicine Complex Care coordinates care for Michigan Medicine patients with the highest level of need, including physical illnesses, mental illnesses, homelessness, and lack of adequate health insurance
  • Packard Health provides health care services to people who are uninsured, isolated, and medically vulnerable
  • St. Joseph Mercy Health System offers a range of services–from telemedicine to complex care management–at five hospitals that are committed to encouraging the healing of body, mind and spirit
  • Washtenaw County Community Mental Health provides mental health services to adults with a severe and persistent mental illness, children with a severe emotional disturbance, and individuals with a developmental disability
  • Washtenaw Health Plan works to expand access to health care services through a safety net health care program, Medicaid and Marketplace enrollment assistance, community health workers, and more

Partner entities

In the first 18 months of the intervention, most of the work was managed by the founding partners listed above, as well as by leaders of the Washtenaw Health Initiative and staff from the WHI’s backbone organization, the Center for Health and Research Transformation.

In the summer of 2018, the Shelter Association of Washtenaw County joined the founding organizations to refer participants, deliver key services to those enrolled in the pilot, contribute to care coordination, and more. CHRT has been working with Medicaid health plans, as well, with the goal of providing more coordinated services and a possible path toward sustainability.

It is our hope that additional community organizations will join in the coming year.