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United Way Blog

Busting Silos To Improve Health Care

You may not know what or where the Jackson Community Care Hub is, but to Ken Toll, it’s the most powerful tool he’s seen in his 20 years in nonprofits.

It’s a technology platform in Jackson, Michigan that integrates health care between 50 disparate organizations, including hospitals, nonprofits, businesses and schools. And it’s an example of how United Way is tapping into innovative solutions and strategies in our fight to improve the health of every person in every community.

As a beneficiary of a State Innovation Model grant, United Way of Jackson County (where Toll is President and CEO) was encouraged to create an accountable health community to break down traditional silos in the medical community, social services and government.

Addressing social needs in health care is pivotal because unmet social needs create poor health outcomes. Today, patients with multiple health and social needs are too often forced to navigate our fragmented system by themselves. But when medical and social service providers work together, we can address community and individual needs from a more holistic viewpoint. 

The Jackson Community Care Hub integrates care between participating organizations to conduct medical and social needs screenings, make referrals to appropriate resources and communicate with other service organizations. Ken Toll, a former database programmer and expert in the nonprofit world, joined forces with Dr. Mike Klinkman, a family practitioner from University of Michigan with experience in clinical information systems, to develop the technology platform.

It took 18 months. The team employed a sociotechnical approach to create a standardized assessment and shared vision of what this tool could do. The hub was co-designed with 20 critical human service agencies through interviews, facilitated discussions and workshops. A notable pain point was creating the standardized assessment. Across a working group of eight agency partners, each had a different intake and assessment process!

And the focus never strayed from the patient’s experience. Whenever the group hit a roadblock, Dr. Klinkman brought in a cardboard cut-out of a patient -- and the group walked through a case analysis to understand each agency’s process. Through this process, they created a universal social needs assessment, drawing on the acclaimed Arizona self-sufficiency matrix, which uses the same language as 211, the go-to resource that connect people to local resources across 96% of America and in Canada.

To build the technical infrastructure, Ken enlisted Riverstar, a software consultant and trusted partner. Riverstar created built-in protocols and processes within the Hub to facilitate a “close loop” referral system -- to ensure accountability. That means when a referral is made, the platform will wait a certain number of days before reminding providers that a client is waiting for service.

The Hub is connected to more than 50 organizations, including hospitals, nonprofits, businesses and schools.  It’s integrated with the Michigan Health Information Exchange, and embedded into the electronic health records of all Jackson County residents. As a result, the Hub data is directly connected to and stored within each person’s medical record, and directly connected to all the medical care billings held by the Michigan Health Information Exchange. Sounds complicated, but it means that the Jackson Community Care Hub can perform longitudinal evaluations on health outcomes, emergency room visits, chronic health conditions, costs and more. Privacy is ensured: the Hub is HIPAA-compliant and assigns each client a unique identification number.

Since implementation, the Hub has screened one-third of Jackson County residents (31,051 people) and is largely used by physicians. During COVID-1, the Community Care Hub is improving community health outcomes, and addressing underlying conditions that make individuals more susceptible to the virus. It’s innovation that’s making people safer.

*This is part of the “United Way Most’s Innovative Minds” List, celebrating individuals who embrace innovative methods to reshape the future of social impact. Learn more here.

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