Social and Medical Care Coordination Intervention

People who frequently visit the emergency department sometimes have both severe health problems and a range of social needs that complicate those problems. To improve their health, they often need an array of supportive services such as a primary care provider they can get to easily, safe and affordable housing, healthy foods, mental health counseling, substance use treatment, and more.

While people who are healthy and highly motivated can generally secure these additional supports by working with local agencies, some people have a hard time identifying the right agencies and navigating the complex requirements to secure health and social services in the community.

The Livingston and Washtenaw County Community Health Innovation Region, with funding from the Michigan Department of Health and Human Services, is attempting to address this problem by providing 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. Program planning and design lasted from the summer of 2016 through the summer of 2017, and the pilot began to enroll its first participants in the fall of 2017.

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. These care coordinators use a predictive model to prospectively identify participants who frequently use the emergency department and to communicate with one another across a shared IT platform, MiCareConnect, hosted by PCE systems.

The Livingston and Washtenaw County Social and Medical Care Coordination pilot, which is now serving more than 250 residents in the participating counties, will continue through November 2019. A number of quantitative and qualitative studies are underway to measure the impact on the participants, the agencies serving them, and the community at large.