By Natasha Robinson, MPCA Communications Specialist
Health Delivery, Inc. (HDI) will soon begin its part of a new program called Saginaw Pathways to Better Health, an innovative personalized care model.
The Saginaw-based Health Center is one of the care coordination agencies who will recruit and train Community Health Workers (CHWs) to help improve health outcomes for adults insured by Medicare, Medicaid, or both. Another goal of the Pathways model is to reduce the cost of care for chronic conditions such as diabetes and high blood pressure. The program is expected to begin accepting patients on February 4, 2013.
“The Michigan Pathways to Better Health will help HDI take better care of our patients, engage them into cost effective care, help them become part of our medical homes, and improve our community – all very much in line with HDI’s mission,” said Lisa Burnell, RN, BSN, vice president of clinical services at HDI.
The program will be based on the Pathways Community Hub model. This puts specially trained CHWs in regular contact with patients so they are able to monitor living conditions and other factors that may affect management of their disease — from nutrition to transportation. Burnell said some of the model’s pathways will work with patients on medical homes, medication management, smoking cessation, social service referral, family planning, pregnancy, and postpartum. Each patient is assigned a team consisting of a CHW, a supervising nurse and a social worker.
HDI has already recruited four CHWs, three of them from within the Health Center. Over the course of the grant-funded program, HDI will expand to up to 13 CHWs working through the Pathway processes with patients, Burnell said. The entire program is expected to enroll up to 1,500 patients in Saginaw County.
Michigan Health Information Alliance (MiHIA) and Alignment Saginaw are co-conveners of the Saginaw County program. Covenant HealthCare, St. Mary’s of Michigan and HDI are the care coordination agencies who will recruit and train CHWs, while Saginaw County Community Mental Health Authority serves as the grant fiduciary and provider of Hub services.
The program will be funded as part of a $14 million health care innovations grant from the U.S. Centers for Medicare and Medicaid Services. The recipient agency is the Michigan Public Health Institute, which coordinates the initiative in three target areas: Saginaw County, Muskegon County and Ingham County.