The Greater Flint Health Coalition (GFHC) is one of five organizations chosen by the Michigan Department of Health and Human Services (MDHHS) to lead the implementation of the State Innovation Model (SIM) within their communities. As the backbone organization for the Genesee Community Health Innovation Region (CHIR), the GFHC and its multisector partners are working to improve population health in Genesee County.
What is SIM?
SIM is a Centers for Medicare and Medicaid Services (CMS) Innovation Center initiative that partners with states to advance multi-payer health care payment and delivery system reform models in an effort to achieve better quality of care, lower costs, and improved health outcomes for Medicaid beneficiaries. The State of Michigan was one of eleven states awarded a four-year model test award, focused on implementing Michigan’s Blueprint for Health Innovation.
The vision for Michigan’s State Innovation Model is a person-centered health system that is coordinating care across medical settings, as well as with community organizations, to address social determinants of health to improve health outcomes; and pursue community-centered solutions to upstream factors of poor health outcomes. MDHHS is implementing the SIM initiative under three main umbrellas: population health, care delivery, and technology.
Community Health Innovation Regions
To address population health, MDHHS has funded five Community Health Innovation Regions (CHIRs) across the State. In addition to the GFHC’s Genesee CHIR, there are CHIRs in the Jackson, Muskegon, Northern Michigan and Livingston/Washtenaw County communities. CHIRs are broad partnerships of community organizations, local government agencies, businesses, healthcare providers, payers, and community members that collaborate to align and implement strategies to support population health.
SIM Priority Population
MDHHS has required Community Health Innovation Regions to focus on the SIM priority population of emergency department (ED) utilizers. The selection of this priority population is supported by the Genesee CHIR’s Community Health Needs Assessment (CHNA), adopted by Genesee County’s three hospitals and the GFHC. The GFHC and its stakeholders have defined this SIM priority population as:
1. High ED utilizers, or individuals using the ED five or more times in a year
2. “Inappropriate” ED utilizers, or individuals using the ED to receive care for conditions identified as typically treatable in a primary care setting; and
3. Preventable ED utilizers, or individuals using the ED who have not had a visit with their primary care provider in the previous year.
GFHC Clinical-Community Linkage Initiative
A primary goal set by MDHHS for each Community Health Innovation Region is to address non-medical factors that affect health, such as housing, transportation, and food insecurity, by supporting connections between primary care practices and community service providers, often referred to as clinical-community linkages. The Clinical Community Linkage Project is led by the Greater Flint Health Coalition, which has implemented a community “hub” model based on the early success of its Genesee Children’s Healthcare Access Program, or CHAP.
To achieve this goal of developing a functional clinical community linkage process, the GFHC has partnered with a variety of community stakeholders and institutions. These include, but are not limited to:
• Two local physician organizations: Professional Medical Corporation and McLaren Physician Partners;
• Genesee County’s six Medicaid Health Plans: Molina Healthcare, McLaren Health Plan, Meridian Health Plan, Blue Cross Complete, UnitedHealthcare Community Plan, and HAP Midwest;
• Genesee County’s three hospitals: Hurley Medical Center, Ascension Genesys Hospital, McLaren Flint;
• Three community-based specialty hubs: Genesee CHAP, Genesee Health Plan, and Genesee Health System;
• The local regional health information exchange (HIE), Great Lakes Health Connect;
• A collective of community and social service organizations including: United Way of Genesee County, Catholic Charities, Carriage Town Ministries, Child Care Connect, Crossover Downtown Outreach Ministries, Food Bank of Eastern Michigan, Genesee County Community Action Resource Department (GCCARD), Mass Transportation Authority, My Brothers’ Keeper, Salvation Army, Shelter of Flint, Valley Area Agency on Aging, and YWCA of Greater Flint.
A newly launched Community Referral Platform is providing one platform linking participating practices, community-based specialty hubs, and community service agencies to support the needs of patients. Working together, the GFHC and its partners will address the upstream socio-economic factors affecting the health of Genesee County residents. An initial ten SIM-designated patient centered medical home (PCMH) practices are included in the Clinical Community Linkages pilot phase launch that began in November, 2017.