Health Care Innovation Awards: Project Profile


Project Title: "Michigan pathways to better health"
Geographic Reach: Michigan
Funding Amount: $14,145,784
Estimated 3-Year Savings: $17,498,641


The Michigan Public Health Institute (MPHI), in partnership with the Michigan Department of Community Health (MDCH) and local community agencies, implements the Michigan Pathways to Better Health (MPBH) initiative.  MPBH supports the CMS goals of better health, better care, and lower cost by assisting beneficiaries to address social service needs and link them to preventive health care services.

MPBH is based on the Pathways Community HUB Model developed by Drs. Sarah and Mark Redding of the Community Health Access Project (CHAP). Community Health Workers (CHWs) are trained and deployed to assist Medicaid and/or Medicare adult beneficiaries with two or more chronic conditions with health and social service needs (such as primary care, housing, food, and transportation). In other states, the model has improved health outcomes and lowered healthcare costs.

Three high-need counties (and selected adjacent counties) are served: Ingham, Muskegon and Saginaw. In each county, a number of organizations work together to implement the model. The Lead Agency is the fiduciary, managing contracts and finances, and providing project oversight.  Referrals to the program are made by healthcare providers, social service agencies, CHWs, and other community agencies. The Pathways Community HUB conducts outreach, accepts referrals, determines client eligibility, enrolls clients and assigns clients to a Care Coordination Agency (CCA). The HUB also manages the IT function, provides quality monitoring and improvement, and reports on outcomes to the CCAs and the community. CCAs deploy and manage the CHW workforce, receiving assignments from the HUB.  Partners work together to identify, recruit, and train CHWs who live in the community. Before serving clients, CHWs receive training based on a curriculum developed by Dr. Sarah Redding. As CHWs work in the field, they are mentored by experienced CHWs and supervised by a registered nurse and/or social worker.  CHWs do not provide direct healthcare or human services, but link clients to these services.

Over three years, MPBH will employ 75 CHWs and serve over 13,000 clients. The project will demonstrate the role of CHWs and Pathways Community HUBs in improving health outcomes and chronic disease management, while lowering healthcare costs by an estimated $17,498,641.

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