SDOH Hub Pilots

SDOH Hub Pilot Sites

Cohort One

The first cohort of SDOH Hub pilot sites launched in January 2024:

1: Lead Organization: Detroit Health Department

Jurisdiction: City of Detroit

Key Partners: Wayne County Health Department, United Way of Southeast Michigan

Overall goal: Capacity building for community-based organizations.

Activities:

1. Establish a localized community information exchange (CIE) and coordinate efforts with regional and state CIEs.
2. Address upstream SDOH needs to advance health equity.
3. Update and publish a Community Health Assessment (CHA).
4. Implement a Community Health Improvement Plan (CHIP).

2: Lead Organization: District Health Department #10

Jurisdiction: 10 counties in middle-northwest Michigan, including Crawford, Kalkaska, Lake, Manistee, Mason, Mecosta, Missaukee, Newaygo, Oceana, and Wexford

Key Partners: North Central Community Health Innovation Region, Disability Network West Michigan, Northern Michigan Care Partners, Advanced Health Technology Solutions

Overall goal: Increase capacity for data collection and analysis to drive system change through Community Connections Clinical-Community Linkages (CCL) and CIE development and through Community Health Improvement Plan implementation.

Activities:

1. Expand the interface of the Community Connections platform to a community-based organization for SDOH screening and referral for community health worker (CHW) services.
2. Onboard to the Michigan Health Information Network (MiHIN) and assure the connection to MiHIN through two different use cases.
3. Strengthen relationships with community partners to create and sustain the technology and relationships required to collect SDOH needs and link individuals to CHW services.
4. Implement CHIP strategies specific to the North Central Rural Health Network/Community Health Innovation Region’s (CHIR) Chronic Disease SDOH Accelerator Plan.  

3: Lead Organization: Greater Flint Health Coalition/Genesee United Way

Jurisdiction: Genesee County

Key Partners:

Overall Goal: To align with the MDHHS SDOH Strategy and utilize a health equity in all policies approach to operate the Mid-Michigan Community Health Access Program (CHAP), a clinical-community linkage hub that utilizes a community health worker workforce to address person's health related social needs through connections to community-based organizations, leveraging technology and community information exchange capacities.

Activities:

1. Operate Mid-Michigan CHAP.
2. Utilize CHWs to address health-related social needs for persons referred to CHAP.
3. Build the capacity of the counties within the Mid-Michigan CHAP’s service area to participate in community information exchange.

4: Lead Organization: Wayne County Health Department

Jurisdiction: Wayne County

Key Partners: Detroit Health Department, United Way of Southeast Michigan

Activities:

1. Community health worker/navigator recruitment and training that will help keep kids safe, address behavioral health, address environmental health concerns, as well as food and housing needs.
2. Convene a cross-sector SDOH collaborative to advance health equity.
3. Establish learning opportunities for SDOH, health equity, and social justice.