About

Jackson Health Network (JHN), in partnership with Henry Ford Jackson Hospital (HFJH), expanded the scope of Community Health Workers (CHWs) by embedding them in the Emergency Department and acute care settings. JHN, a clinically integrated network, had seen much success implementing social determinants of health (SDOH) screening in its primary care practices after working with the community to develop a closed-loop referral system: the Jackson Care Hub. JHN utilized CHWs to work in conjunction with their Case Managers and they were essential in bridging the gap between achieving positive medical outcomes and effectively addressing social needs. Unfortunately, there was a significant gap in screening for and assessing SDOH in acute care settings. The workflows and cultures of community-based organizations varied significantly from those in hospital. Recognizing this barrier and understanding the overwhelming impacts that unmet social needs have on the health of a population, JHN applied for and received a Visioning Award from Blue Cross Blue Shield of Michigan to test having a CHW embedded in both the acute care and Emergency Department settings. The goal of this program was to provide people with additional opportunities for engagement with a CHW who could initiate long-term navigation assistance while they were in a vulnerable state of health. The success of this initiative relied heavily on Case Management collaboration, and the program has been sustained since implementation (January 1, 2020). There were multiple learnings and challenges that took place during implementation, and some persist today. However, the information is useful when highlighting the importance of CHWs, and how to incorporate them into Case Management teams (inpatient and outpatient) and acute care settings. A deeper analysis of the direct impacts on utilization is forthcoming, however, as one of many population-based interventions to support value-based outcomes, the organization is experiencing a decrease in overall ED utilization. Lastly, process-based outcomes support that having a CHW in these settings expands the footprint for addressing unmet needs for people in the Jackson community.