In August, members of Livingston-Washtenaw’s Community Health Innovation Region (CHIR), 12 medical and social service agencies—called “hublets”—began the Medical Care Coordination pilot testing of the three-year State Innovation Model (SIM) intervention.
The local intervention was designed to serve residents with complex social and medical needs—to reduce unnecessary emergency department use across the region. Potential participants were identified in one of two ways: provider referrals or a predictive model. These lists were shared with the intervention hub, the Center for Health and Research Transformation (CHRT).
After residents consented to participate, they worked with a care manager at one of the hublets to identify social and medical needs and to set goals about how to address their needs. The assessment and care plan were stored in a shared care coordination platform that was accessible and editable by all hublets.
The original intervention hublets included Avalon Housing, Michigan Medicine Complex Care Management Program, Corner Health Center, Home of New Vision, Jewish Family Services of Washtenaw County, Integrated Health Associates (IHA), Livingston Catholic Charities, Livingston County Community Mental Health, Packard Health, St Joe’s Complex Care, Washtenaw County Community Mental Health, and the Washtenaw Health Plan.