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News Release Date : 02/06/2013

Pathways to Better Heath

St. Mary’s of Michigan is proud to be part of a major initiative that will improve healthcare for thousands of low-income Saginaw County residents with chronic disease. Saginaw Pathways to Better Health, an innovative, personalized care model, will improve outcomes for adults insured by Medicare, Medicaid or dual eligibles and help reduce avoidable hospitalizations, unnecessary emergency department utilization, and costs for the care of conditions such as diabetes, asthma, COPD, hypertension and cardiovascular and kidney disease.
 
St. Mary’s of Michigan is one of the care coordination agencies who have recruited and trained Community Health Workers (CHWs) to help improve health outcomes. Patients will be recruited using targeted "hot spotter” data, those with high complex needs and high utilization of care.
 
"The Saginaw Pathways to Better Health will help ensure people are connected to the kind of care they need. We will focus on the most vulnerable to be able to take better care of them as our patients, engage them into cost effective care, help them become part of our medical homes, address their social determinants to health, and improve our community – all of which are very much in line with the St. Mary’s of Michigan mission,” said Cherie Sammis, Vice President of Mission Integration at St. Mary’s.
 
The program will be based on the Pathways Community Hub model. This puts specially trained CHWs in regular contact with patients so they are able to monitor living conditions and other factors that may affect management of their disease - from nutrition to transportation. Each patient is placed on one or more specific "pathways” - each a framework for results-oriented care planning designed expressly for management of a specific chronic illness.
 
Sammis said some of the model’s pathways will work with patients on medical homes, medication management, smoking cessation, social service referral, transportation, etc... Each patient is assigned a CHW, with supervision from a nurse and a social worker. The CHWs link patients to resources and are complementary, not redundant, to any existing care coordination.
 
This program replicates St. Mary’s of Michigan’s Center of HOPE (health, opportunity, education, and pharmacy assistance) program with existing CHWs. Over the course of the grant-funded program, St. Mary’s will expand to up to 12 CHWs working through the Pathway processes with patients, Sammis said.
 
St. Joseph Health in Tawas will also participate with their Community Health Workers, expanding access across our region. The entire program is expected to enroll up to 1,500 patients in Saginaw County.
 
Michigan Health Information Alliance (MiHIA) and Alignment Saginaw are co-conveners of the Saginaw County program. Covenant HealthCare, St. Mary’s of Michigan and Health Delivery, Inc. are the care coordination agencies who will recruit and train CHWs, while Saginaw County Community Mental Health Authority serves as the grant fiduciary and provider of Hub services.
 
The program, which started to accept patients on February 4, will be funded as part of a $14 million health care innovations grant from the U.S. Centers for Medicare and Medicaid Services. The recipient agency is the Michigan Public Health Institute, which coordinates the initiative in three target areas: Saginaw County, Muskegon County and Ingham County.
     

800 South Washington Avenue | Saginaw, MI 48601 |
(989) 907-8000 | 1-844-907-8000
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