To integrate community health workers (CHWs) into primary care teams in the county of Ingham and cities of Saginaw and Muskegon. These CHWs will coach patients on self-management of conditions and encourage regular primary care visits. In addition, the program will connect at-risk populations with local care and support services that address social determinants of health that impede achievement of positive health outcomes. This "Pathways Community Hub" model will decrease hospitalizations and emergency department visits by improving adherence to therapy, improving access to primary care and increasing use of preventive care and support services. Over a three-year period, the Michigan Public Health Institute will train over 231 people and hire 87 people to serve as community health workers, providing care self-management coaching, care navigation services, and care coordination services. $14,145,784 funding from CMS
