In 2015, the Washtenaw Health Initiative was selected by the Michigan Department of Health and Human Services to coordinate the Livingston-Washtenaw Community Health Innovation Region (CHIR)–one of five regional health initiatives across the State of Michigan. These regions work to improve health by addressing some of the upstream social and economic factors that influence health, such as housing, transportation, employment, and more, through two interventions:

• The Patient-Centered Medical Home (PCMH) Initiative requires participating primary care practices to screen patients annually for social needs–including food insecurity, access to stable housing, and more–and to connect willing patients to community-based resources that can help them meet those needs.
• The Community-Clinical Linkages Program Initiative forges and strengthens connections between health care providers and community-based organizations–such as homeless shelters, drug treatment programs, and food pantries–to address health and human service needs in concert.

As backbone organization to the Washtenaw Health Initiative, CHRT receives State Innovation Model funding to facilitate the three-year pilot:

• In our regional Patient-Centered Medical Home pilot, 54 medical homes are screening patients for food, housing, financial, transportation, literacy, and public utility needs. Michigan Medicine medical homes are also screening for employment needs, and Integrated Health Associates (IHA) and Huron Valley Physicians Association (HVPA) medical homes are screening for social isolation, child care, and elder care needs.
• In our regional Clinical-Community Linkages Intervention, more than a dozen health and social service agencies are working together to coordinate care for frequent users of emergency department services. Participants are selected either through a referral or through a predictive model designed to identify individuals who may become frequent emergency department utilizers. Participants then receive assistance with housing, transportation, mental health, substance use, food access, and other needs.

Dozens of Washtenaw Health Initiative members–both individuals and organizations–have worked to design and implement the pilot, to serve patients and participants who are enrolled, to record care plan steps, and to improve health outcomes for some of the most vulnerable residents of Livingston and Washtenaw Counties.

The Center for Health and Research Transformation (CHRT) serves as the backbone organization for the Washtenaw Health Initiative and the Community Health Innovation Region. As such, CHRT facilitates dialogue between partners, manages data collection and analysis, supports internal and external communications, conducts community outreach, secures additional funding, maintains fiduciary responsibilities, and both conducts and manages evaluations. Through this work, CHRT helps to achieve the objectives established by state health policy leaders and local health and human service providers.