Community-Clinical Partnerships

Collaborating with community and clinical partners to close the gap between healthcare and social service systems across the state.

Clinical care accounts for just 20% of patients’ health outcomes but represents the overwhelming majority of health care spending. Addressing Social Determinants of Health requires systems-level change—together we can build a bridge to better health.

MSHIELD partners with organizations across Michigan doing the work to build healthier communities. As a partnering Collaborative Quality Initiative (CQI), we connect community organizations with other CQIs and their participating healthcare providers to address social health needs and link patients to local resources for food insecurity, housing instability, transportation, and more.

Our Approach

There is a growing evidence base showing that interventions addressing patients' social health needs are associated with better health outcomes, lower costs, or both. MSHIELD supports CQIs to expand these interventions to specialty care settings. Our work is intentionally community-driven and co-developed. We bring together community hubs, CQIs, and clinicians to screen patients for social health needs, link them to resources, and collect data to assess clinical outcomes and improve practices.

MSHIELD supports our partners through every stage of implementing closed-loop social needs screening and referral:

1: Planning

Based on community-identified priorities, MSHIELD convenes the community hub, CQI, and specialty care clinic in preparation for implementing social needs screening and referral

2: Screening

Clinic screens patients for social health needs like food, housing, and transportation

3: Referral

Clinic refers patients with social health needs directly to the community hub

4: Linkage

Community hub connects patients to resources and coordinates services

5: Feedback

Community hub closes the referral loop and provides feedback on the outcome of the referral to the clinic, CQI, and MSHIELD

6: Reporting

MSHIELD conducts process evaluation; partners collect data to assess whether clinical outcomes vary by unmet social health needs

Our Partners

To address patients’ social health needs, MSHIELD works closely with community hubs across Michigan that provide care coordination services, connect patients to community resources, build community capacity to address health inequities, and drive improvements in population health.

We're proud of our existing partnerships and always welcome opportunities for new connections. Read about our current partners or contact our team to learn more.

Our Impact: Early Success in Genesee County

Along with the Michigan Bariatric Surgery Collaborative and local partners, MSHIELD built a referral pathway to resources for bariatric surgery patients. Patients are screened for social health needs at the McLaren Flint Bariatric and Metabolic Institute and referred to the Mid-Michigan Community Health Access Program where case managers connect them to resources and services.