The Michigan Value Collaborative

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

Tag: Social determinants of health (page 1 of 2)

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:

Addressing social determinants through integrated care

Deby Evans

Deb Evans is the MVC Site Engagement Manager

Despite being one of the world leaders in medical care and research, the United States (U.S.) spends the most amount of money on healthcare, yet better patient outcomes are subject to debate. Not only do physical ailments and mental health disorders affect the health of the population, but social determinants, such as environmental factors, education and transportation availability, also play a prominent role in determining health outcomes. The U.S. healthcare system has typically focused on providing care for physical conditions and diagnoses, yet many patients may have a secondary behavioral health condition. In addition, all patients have their own specific set of social determinants that should be taken into consideration when providing healthcare. These factors ultimately impact behaviors and health outcomes of individuals.

A white paper published by Deloitte Consulting discusses the implications of social determinants on patient outcomes and healthcare costs. It encourages us to seek out and investigate methods to provide more integrated patient care within hospital systems and the U.S. healthcare system as a whole.

Addressing social determinants is a challenge for healthcare providers but a necessary one to help improve patient outcomes along with the added benefit of reducing costs. Some of the ways hospitals can respond to this challenge is by implementing coordinated care, care management or integrated care programs. However, despite varying existing program models, each type brings its own barriers with accessibility, communication and information management being the most complex. By working through these barriers and integrating care for patients, hospitals have the potential to not only affect patient outcomes but also reap the benefits of controlling costs. Rush University Medical Center, for example, is using a tool in their emergency department that allows them to screen for social and structural determinants of health. When used in conjunction with a recently instituted community health needs assessment and the community health implementation plan, this method helps address healthcare disparities in the local neighborhoods and brings positive changes to their patient outcomes.

For more information on the Deloitte paper:

For more information on Rush University Medical Center: or


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