To qualify, participants should meet three or more of the following criteria:

1) Three or more chronic medical conditions
2) No primary care engagement in the past two years
3) Social needs, such as food or financial insecurity, transportation needs, insurance
4) A mental health or substance use related need
5) Homelessness or housing instability
6) Five or more emergency department visits in the last 12 months
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Our housing providers, mental health and substance use counselors, complex care management programs, health clinics, and social service providers have developed tools and techniques that remove barriers to care for people with complex needs including:

1) Shared consent forms and a secure, interoperable information technology platform as well as regular care coordination meetings
2) Accountable care partnerships with a dozen medical, behavioral, and social service providers in Livingston and Washtenaw Counties
3) Shared community health workers and peer support specialists who have strong community relationships, lived experience overcoming health and personal challenges, and specialized knowledge of local resources

If one or more of your patients/clients meet our referral criteria, talk to them about the program. You may give them our participant informational flyer, designed with their interests in mind. If your patient/client is interested, submit our short referral form, telling us what you can about their needs.

Referrals will be carefully reviewed by our care managers. Staff may call your office to discuss candidates before making a final decision, so please make time to talk to them. Individuals who meet our program criteria will be accepted based on capacity at the time of referral.