Funded by Michigan Department of Health and Human Services (Subcontract)
Investigators from University of Michigan’s Institute for Healthcare Policy and Innovation (IHPI), in partnership with the Detroit Health Department, the Southfield-Joy Community Development Corporation and five health plans insuring Detroit-based Medicaid and Healthy Michigan enrollees have collaboratively developed an innovative new model for a Community Health Worker-led (CHW) demonstration project in Detroit’s Cody Rouge neighborhood. The demonstration project will evaluate a potentially financially sustainable model targeting neighborhoods with high numbers of high- and under-health care utilizing Medicaid enrollees. The health plans will each deploy one of their CHWs to the project for a 12-month period. After undergoing joint training through the Michigan Community Health Worker Alliance (MICHWA) program and using assessment tools that cover shared domains, the CHWs will proactively reach out to identified beneficiaries to conduct an initial health and social needs assessment, develop an individualized ‘action plan’ with each beneficiary, work with neighborhood-based organizations to address each enrollee’s unique needs, and provide follow-up support as needed. CHWs will work closely with local organizations both to meet program participants’ needs and to strengthen community capacity to bridge gaps between healthcare services and community-level social determinants of health. The Detroit Health Department will provide office space for the CHWs to meet weekly in a neighborhood facility and provide ongoing booster support and mentorship. UM investigators will evaluate the program in a parallel, two-armed, randomized controlled pragmatic trial. We will evaluate effect on health care utilization among high-utilizing participants and zero-utilizing participants (ED visits, hospitalizations, primary care use) and health care costs at 6- and 12-months and compared to eligible individuals not yet enrolled in the project, on key patient-centered outcomes, and project costs, return on investment, and barriers and facilitators to adoption, implementation, maintenance, and potential spread.