SDOH Hub Pilots

8: Name of Lead Organization: Chippewa County Health Department

Jurisdiction: Chippewa County

Key Partners: Chippewa-Luce-Mackinac (CLM) Community Action Agency

Overall goal: Increase capacity for data collection, leading to enhanced accessibility of resources for disparate populations.

Activities: 

1. Survey and assess service needs/gaps within Chippewa County.
2. Develop a community information exchange.
3. Expand and strengthen relationships with community partners to link individuals to community health workers.

8: Name of Lead Organization: Chippewa Luce Mackinac (CLM) Community Action Agency

Jurisdiction: Chippewa County

Key Partners: Chippewa County Health Department

Overall goal: Implement a social determinants of health Outreach Resource Advocate (ORA) Project. 

Activities: 

1. Reach and educate clients in underserved areas, located away from CAA centers.
2. Locate and identify potential vendors/partners.
3. Visit existing service points in the community.
4. Evolve into interacting with local clergy, civic organizations, etc. to include attending local meetings.
5. Evaluation of effectiveness: review of project for increased client intakes, referrals, and services provided.

9: Name of Lead Organization: District Health Department #4

Jurisdiction: Alpena, Cheboygan, Montmorency, and Presque Isle counties

Key Partners: Benzie-Leelanau Health Department, District Health Department #10 (Northern Michigan Public Health Alliance)

Overall goal: To implement a SDOH Hub that aligns with MDHHS goals for CIE and CHW services with data integration through MiHIN.

Activities: 

1. CIE: Expand interface of the Community Connections Platform (Pathway Technology Solutions-PTS) to create an interface with MiHIN and demonstrate the connection through two different use cases.
2. Develop a process for community health workers to best utilize information received from the data exchange for enhanced navigation.
3. Community Connections CHWs will work with participants to identify and address SDOH needs.

9: Name of Lead Organization: Benzie-Leelanau District Health Department

Jurisdiction: Benzie and Leelanau counties

Key Partners: District Health Department #4, District Health Department #10 (Northern Michigan Public Health Alliance)

Overall goal: To implement a SDOH Hub that aligns with MDHHS goals for CIE and CHW services.

Activities: 

1. CIE: Expand interface of the Community Connections Platform (Pathway Technology Solutions-PTS) to create an interface with MiHIN and demonstrate the connection through two different use cases.
2. Develop a process for community health workers to best utilize information received from the data exchange for enhanced navigation.
3. Community Connections CHWs will work with participants to identify and address SDOH needs.

10: Name of Lead Organization: Kent County Health Department

Jurisdiction: Kent County

Key Partners: Heart of West Michigan United Way, HealthNet of West Michigan

Overall goal: Cultivate partnerships with community collaborators and develop a method for the collection and utilization of SDOH data.

Activities: 

1. Formalize key partnerships for data collection.
2. In collaboration with community partners, develop software for data collection and engagement.
3. Utilize SDOH screener, collect data, and utilize data to connect community members to needed resources.

11: Name of Lead Organization: Michigan Thumb Public Health Alliance

Jurisdiction: Huron, Lapeer, Sanilac, and Tuscolacounties

Key Partners: Huron County Health Department, Lapeer County Health Department, Sanilac County Health Department, Tuscola County Health Department

Overall goal: Increase access to SDOH services and reduce barriers for residents in Huron, Lapeer, Sanilac, and Tuscola counties.

Activities: 

1. Increase access to navigation services in the Thumb Region.
2. Strengthen referral networks across sectors (medical, public health, social services, education, and behavioral health).
3. Various community stakeholders across sectors agree on a SDOH Hub model.
4. Develop a sustainable plan for staffing the SDOH Hub model.

12: Name of Lead Organization: Saginaw County Health Department

Jurisdiction: Saginaw County

Key Partners: PartnerShift Network

Overall goal: Develop and implement an electronic closed-loop referral community information exchange (CIE) operated by a network of Community Health Navigators across Saginaw.

Activities: 

1. Engage and partner with Bay County CIE development to understand and develop a plan for Saginaw implementation of the technology.
2. Establish a CIE Saginaw-based Steering Committee to drive all planning and implementation.
3. Establish the Community Resource Program, staffing, and CHW training to oversee CIE implementation.
4. Implement Bright Street build CIE and pilot with identified agencies.
5. Develop training and outreach plans based on the pilot launch to engage full implementation.
6. Develop a regional CHW network.

12: Name of Lead Organization: PartnerShift Network

Jurisdiction: Saginaw County

Key Partners: Saginaw County Health Department

Overall goal: Saginaw County Health Department and PartnerShift Network will work collaboratively to streamline available community resources through development and implementation of a Community Information Exchange (CIE) system and trained navigators to address Social Determinants of Health (SDOH) in Saginaw County.

Activities: 

1. Increase availability of CHWs.
2. Increase access to Success Coaches (certified as CHWs).
3. Foster collaboration among stakeholders.
4. Streamline access to community resources for the ALICE population.
5. Evaluate long-term programming needs.

13: Name of Lead Organization: United Way for Southeastern Michigan

Jurisdiction: Wayne County

Key Partners: Detroit Health Department, Wayne County Health Department

Overall goal: As an SDOH Hub supporting community-led interventions in Wayne County, United Way with lead efforts with partners to develop and implement a partner engagement approach in addition to supporting Food Delivery Service Program activities.

Activities: 

1. Implement a foundational infrastructure to support SDOH hub work in Wayne County that can adapt to partner and community needs.
2. Support the planning, implementation, and evaluation of food service delivery program in Wayne County.

14: Name of Lead Organization: Berrien County Health Department

Jurisdiction: Berrien County

Key Partners: Region IV Area Agency on Aging (AAA)

Overall goal: Address the social needs of Berrien County residents through collaboration, referrals, and policy change.

Activities: 

14: Name of Lead Organization: Region IV Area Agency on Aging (AAA)

Jurisdiction: Berrien County

Key Partners: Berrien County Health Department

Overall goal: Address the health-related social needs of Berrien County residents through collaboration, referral and linkage, and policy change.

Activities: 

1. Improve capacity, coordination, and access to community health workers across medical and social services.
2. Develop community information exchange solution for closed-loop referrals for SDOH screening and linkage to home and community-based services.
3. Expand capacity of community-based organizations to meet the needs of the target population.
4. Develop a comprehensive data analysis and reporting system capable or driving data-informed decision making for Health in All Policies strategies. 
5. Enhance health and social service partnerships and collaboration frameworks for data-informed strategic planning and collective impact strategies towards upstream solutions.