Michigan Pathways to Better Health

Funder: Centers for Medicare and Medicaid Services
Partners: Michigan Department of Community Health; local community agencies
Funding Amount: $14 million

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 Centers for Medicare and Medicaid Services’ goals of better health, better care, and lower cost through improvement, by assisting beneficiaries to address social service needs and link them to preventive health care services. Community health workers (CHWs) are trained and deployed to assist Medicaid and/or Medicare adult beneficiaries who have two or more chronic conditions and have health and social service needs (such as primary care, housing, food, and transportation). In other states, the model has improved health outcomes and lowered health care costs.

Three high-need Michigan counties are served by the project, Ingham, Muskegon and Saginaw. In each, a number of organizations work together to implement the model. The lead agency is the fiduciary, managing contracts and finances and providing project oversight. MPHI also developed a comprehensive case management system that assesses participants’ needs. Health care providers, social service agencies, CHWs, and other community agencies refer participants to the program.

The Pathways Community HUB conducts outreach, accepts referrals, determines client eligibility, and enrolls 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 on a curriculum developed by Drs. Sarah and Mark Redding, originators of the Pathways Community HUB model. CHWs are mentored by more experienced CHWs and are supervised by a registered nurse and/or social worker. CHWs do not provide direct health care or human services, but link clients to services.

Over the project’s three years, MPBH will employ 75 CHWs and serve more than 13,000 clients. The project will demonstrate the role of CHWs and Pathways Community HUBs in improving health outcomes and utilizing preventive health care, while lowering health care costs.

The project described was supported by Grant Number 1C1CMS331025 from Department of Health and Human Services, Centers for Medicare and Medicaid Services. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of Department of Health and Human Services, Centers for Medicare and Medicaid Services.


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