The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Using Community Health Workers (CHWs) to Address Complex Needs Patients

Shiyuan Yin

Shiyuan is the MVC Research Associate.

Community Health Workers (CHWs) have been identified as a way to potentially expand healthcare access and reduce overall costs of care for complex patients. The effectiveness of CHWs stems from their knowledge and experiences in addressing social determinants of health as well as their unique position as a liaison between healthcare providers and patients. Challenges in integrating CHWs into the care continuum have limited their full potential to improve patient outcomes.

The Center for Healthcare Research & Transformation (CHRT) recently reviewed how CHWs have been integrated into value-based health systems nationally through the State Innovation Model (SIM) grants.  CHRT also examined how states utilized their grant to address challenges in both workforce development and integration demonstrations [1].  As part of its research, CHRT also documented how each SIM awardee addressed sustainable funding for CHW integration after the grant expires.

Among states receiving SIM test awards interviewed by CHRT, the state of Michigan develops the CHW workforce by expanding its core competency-based training program.  Michigan also uses grant funds to recruit and train new instructors while offering the program at community colleges throughout the state. In Michigan, the focus is to integrate CHWs into Patient-Centered Medical Homes (PCMHs) to help address emergency department utilization and improve overall social determinants of health.  Monthly payments to PCMHs provide seed funding for CHWs.

As an example of states using SIM dollars to integrate CHWs into the care continuum, CHRT cited Vermont’s employment of CHWs as part of a nurse-led community health team.  The purpose of the team is to provide outreach to individuals and bridge relationships among primary care offices and social service groups.  Given the complexities surrounding patient referrals to social services and lack of information exchange with the primary care office as to whether services were received, the state viewed CHWs as an opportunity to bridge these gaps.  Even after the SIM grant ended, the community health teams continue.

While the value of CHWs has been recognized, CHRT determined sustainable funding for these types of support remains uncertain. Moreover, the lack of a standard understanding of the roles of CHWs hinders the effectiveness of their activities and creates confusion. This report provides a great introduction to the core roles, skills, and ideal qualities of CHWs in the U.S [2].

If you are interested in learning how other states use CHWs to address patients’ social and personal needs and allow primary care providers to focus on clinical needs, you may want to refer to this toolkit designed by the Office of Rural Health and Primary Care at the Minnesota Department of Health.

Interested in reading more? Please check out the following sources:

  1. Lapedis, Kieffer, and Udow-Phillips, “Revisioning the Care Delivery Team: The Role of CHWs within State Innovation Models.” Retrieved from:
  2. Rosenthal, Rush, and Allen, “Understanding Scope and Competencies: A Contemporary Look at the United States Community Health Worker Field.” Retrieved from:

MVC Heart Failure Workgroup Updates and 2018 Opportunities

Deby Evans

Deb Evans is the MVC Site Engagement Manager

The Michigan Value Collaborative (MVC) Congestive Heart Failure (CHF) workgroup has had a productive year of virtual meetings and many useful discussions about a variety of topics that can influence reducing readmissions. Every other month, in collaboration with I-MPACT, another Blue Cross Blue Shield of Michigan quality improvement collaborative focusing on transitions of care, the group has held discussions on a variety of topics pertaining to CHF. The MVC Coordinating Center will be opening up the workgroup for other hospitals to join in 2018 and additional information can be found below. A synopsis of the findings of each 2017 workgroup discussion is detailed below, although more details can be found on the MVC registry under the resource tab or by contacting the Coordinating Center.

Using Skilled Nursing Facilities: This discussion encouraged working closely with skilled nursing facilities to help provide education to staff, patients, family members and care givers in respect to fluid intake and nutrition.  Additionally, the discussion included how to allow staff to facilitate medication administration and finding alternative ways of medication delivery such as giving Lasix via intramuscular injection rather than intravenously.

CHF Referrals to Palliative Care: The discussion centered around getting this patient population referred to palliative care as soon as possible in the course of their disease process. The conversation included triggers for referral along with some benefits of being in a palliative care program and initiatives that Michigan hospitals had implemented or were working on implementing in relation to palliative care programs in their facilities.

Use of Outpatient Heart Failure (HF) Clinics: The group discussed the effectiveness of having a HF clinic to refer their CHF patients too and how attendance at these clinics had helped reduce CHF readmission rates. Some hospitals discussed the collaborative work they had done to implement a HF clinic in their facility. Templates of business plans were provided and members provided information on how they had presented and made the case to open a HF clinic at their facility. An interview with a Michigan hospital ranked number 3 in the country was utilized for a blog post.

Diet and Nutrition Education: Some dieticians from member hospitals joined us to discuss the tools and information they share with HF patients at their facilities. Information sheets containing information on alternative spices to use instead of salt were shared and also initiatives and education on how to provide heart healthy meals to patients either by the facility or via a vendor such as Meals on Wheels.

Medication Reconciliation: Pharmacists joined the discussion about their role or potential role in medication reconciliation and also provided some recommendations for the use of different stakeholders in the medication reconciliation process, not only for CHF patients but for other patient populations too. Some facilities discussed how they have also integrated parts of the reconciliation process into their electronic health record systems.

The CHF longitudinal workgroup will be continuing into 2018 with more discussion topics pertaining to CHF and opportunities for collaboration. If you are interested in joining the workgroup, please sign up here.  Further details will be provided in 2018.

If you have any questions about the workgroup or 2018 workgroup registration  please contact Abeer Yassine ( or Deb Evans (


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