About CHRT

Developing a community integrated health network to address the social needs of seniors in southeast Michigan

October 2021 – September 2023
Client(s): Administration for Community Living, Ann Arbor Area Community Foundation
Partner(s): Area Agency on Aging 1-B, Catholic Social Services of Washtenaw County, Chelsea Senior Services, Jewish Family Services of Washtenaw County, Ypsilanti Meals on Wheels, Priority Health

The Vital Seniors Initiative (VSI), with a goal of spurring systemic improvements to county senior services, was funded in 2019 by the Glacier Hills Legacy Fund at the Ann Arbor Area Community Foundation. The original VSI grantees were joined by Catholic Social Services of Washtenaw County, a leader in the local aging sector, and the current Vital Seniors Cohort (VSC) includes the Area Agency on Aging 1-B, Catholic Social Services of Washtenaw County, Chelsea Senior Center, Jewish Family Services of Washtenaw County, and Ypsilanti Meals on Wheels.

The Center for Health and Research Transformation has provided backbone support to the grantees and cohort, helping them identify shared values and goals, and chart a course for their work together. This led to the development of a collaborative Senior Services Network (SSN) that worked together to design a pilot Home Nutrition+ pilot to serve vulnerable adults in Washtenaw County during the pandemic.

Priority Health referred vulnerable health plan members–those who are eligible for both Medicare and Medicaid, and who have been diagnosed with diabetes and/or heart disease–to the Home Nutrition+ pilot, which provided medically friendly meals and links to social services for participants.

The pilot design built upon evidence that links medically tailored meals to improvements in health and wellness and that finds that partnering with health care entities can lead to better health outcomes by expanding the care team into the community to meet often overlooked social needs.

Pilot program participants received a health and social services needs assessment, home-delivered medically-friendly meals, and referrals to home and community-based services. An analysis found that the pilot program participants experienced improvements in overall health and wellness, reductions in falls and unnecessary hospitalizations, and more.

CHRT’s role:

With the ACL and Ann Arbor Area Community Foundation grants, CHRT will help the collaborative increase capacity through leadership, management, operations, and strategy; will help the network with legal contracting requirements, coordinated payments, a consistent referral process, and data sharing; onboard new partners who provide services in additional geographic areas; and more.

Through new partnerships, the network, and the Home Nutrition+ program, will be expanded to reach vulnerable populations in additional southeast Michigan counties with high levels of poverty and significant aging populations by establishing a community integrated health network called the Healthy Aging at Home Network (HAHN).

A community integrated health network allows social services providers to be reimbursed for their work through health insurance companies and hospitals. Seniors and other vulnerable adults can receive care from trusted community-based organizations, while having the assurance that these organizations have the sustainable funding that is required to help seniors live comfortably and independently at the home of their choice.

This project is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, ACL/HHS, or the U.S. Government.