New CHRT projects focus on integration, learning networks, and social determinants of health

August 11, 2021

CHRT has launched six new projects over the past few months, including designing a public health and primary care integration demonstration project, participating in a learning action network team to support integrated delivery networks, launching a new practicum and fellowship for Detroit Health Department staff members, and providing training in communicating for policy change to a national network of cancer care organizations.


Coaching members of a national learning and action network of integrated care delivery leaders

National: Institute for Healthcare Improvement (IHI)

While understanding that the social conditions in which a person lives, works, and plays is critical to health, only 24 percent of hospitals and 16 percent of physician offices report screening patients for social needs. More and more, however, health systems are recognizing the imperative of understanding the social needs of their patients and helping to resolve unmet social needs that directly impact health, well-being, and equity. 

In order to support the journey of these health care organizations, Pfizer is funding work with the national Institute for Healthcare Improvement (IHI) to create a Learning and Action Network. CHRT’s executive director will participate in a multi-disciplinary national faculty team that provides coaching and guidance to competitively selected integrated delivery networks. Read more

Integrating public health and primary care and developing sustainable funding mechanisms for both systems

National: American Board of Internal Medicine (ABIM) Foundation

The lack of connection between primary care and public health has had serious consequences during the COVID-19 pandemic. Public health messages about the measures necessary to keep people safe–masking, social distancing, the need for internal eating closures, and the like–have been highly politicized. But in many communities, it was hard for public health leaders to reach and convince their constituents.

CHRT is working with the American Board of Internal Medicine (ABIM) Foundation to Identify ways to integrate public health and primary care and to develop sustainable funding mechanisms to strengthen both systems. In the first phase of this work, CHRT will focus on key informant interviews with representatives from a range of organizations and entities such as public health and primary care professionals from states with advanced integrated systems and states identified by the National Health Security Index 2020. Read more

Expanding the Home Nutrition+ integrated infrastructure

Regional: Michigan Health Endowment Fund

Several national studies have demonstrated a return on investment for nutrition programs. Specifically, a Commonwealth Fund review identified multiple papers that provide strong evidence that medically tailored meals (MTM) improve outcomes and have a positive return on investment. Furthermore, the Commonwealth Fund found that a community-based care transition program, provided to older adults as part of a combined MTM intervention, saved $3.87 for every $1.00 spent, likely driven by a significant decrease in the 30-day readmission rate in the intervention group.

Vital Seniors Initiative grantees–five social service agencies for which CHRT provides backbone support–are forming a community integrated network with the goal of delivering MTM and coordinated service delivery to clients. The end goal: To more effectively and efficiently serve older adults and individuals with disabilities so they can remain in their community and home of choice. To do this, the network needs to develop a hub model structure, governance, and operations as well as new partnerships to expand the Home Nutrition+ program.

CHRT will provide backbone support to the community integrated network, helping network members develop strategic objectives with existing partners, develop the governance structure required to support expansion, set up the appropriate legal agreements, engage with community-based organizations beyond Washtenaw County, and develop the framework to offer Home Nutrition+ based on the “Food is Medicine” model.

During the first quarter, CHRT will identify potential geographic regions for expansion, conduct an analysis of services and gaps of MTM offerings in those regions, engage with a health plan to support the operational objectives for expansion, and conduct visioning sessions to define mission and execute delivery. During the second quarter of the grant period, CHRT will facilitate governance and geographic expansion decision making, set up legal structure and applicable agreements, and more. Read more

Public Health

Developing and delivering a fellowship and practicum for Detroit Health Department staff

Local: Detroit Health Department

In 2019, CHRT launched the Detroit Health Department Public Health Practice and Policy Engagement Fellowship, training two cohorts of DHD staff in four key areas–systems thinking, communications, policy engagement, and data analytics–so they may ultimately lead collaborative, cross-systems work, eliminating silos and addressing the social determinants of health. A shortened, supplemental virtual fellowship for alumni will continue to elevate their public health skills and professional development experience.

CHRT will lead alumni in a six-session fellowship, covering a host of current policy issues and trends. The alumni fellowship will touch on long-standing, complex issues of public health, many of which have been exacerbated by COVID-19. It will create a space to identify and discuss these dynamic problems and provide tangible ways for fellows to address them and affect change. The fellowship also includes a small-group practicum project, focused on real issues faced within DHD departments. At completion, the fellows will have a fleshed-out plan for improving processes–one that is rooted in systems thinking. Read more

Healthy Aging

Informing the development of Michigan’s statewide LTSS strategic plan

State: Michigan Department of Health and Human Services

In 2019, the Michigan Department of Health and Human Services (MDHHS) engaged in preliminary preparation for strategic planning activities around long-term services and supports (LTSS). MDHHS has now asked CHRT to facilitate a comprehensive process to inform a statewide LTSS strategic plan.

In Phase I, CHRT will review MDHHS work to date and interview key staff. CHRT will then conduct an environmental scan of federal policy and funding changes, both planned and existing, as well as examples of how states are applying these federal changes. CHRT will review best practices on equity initiatives and key LTSS options, then develop a white paper on LTSS options. CHRT will also conduct a series of internal and external key informant interviews, and complete a literature review on home- and community-based services, with high-level recommendations for the state. Read more

Communication for Policy Change

Training members of a national cancer care consortium in communicating for policy change

National: Alliance to Advance Patient-Centered Cancer Care 

The national Alliance to Advance Patient-Centered Cancer Care seeks to ensure that findings from the alliance’s six participating sites and cross-site evaluation–particularly those that demonstrate evidence-based mechanisms for advancing patient-centered care and reducing disparities–reach, inform, and inspire national decision and policy leaders.

CHRT is collaborating with the alliance around communicating for policy change. The focus: Developmental editing, as alliance staff write a policy brief to share with national policy and decision leaders, and webinar development and delivery to help alliance members in several states as they communicate their own findings to policymakers and practitioners. Read more