The Promotion of Health Equity Project is a CMS grant-funded partnership, with a mission to design, develop, and implement a new statewide data infrastructure to support quality improvement initiatives in Michigan.

The work provides an opportunity to support BCBSM’s Value Partnerships Collaborative Quality Improvement (CQI) programs in extending their high impact clinical quality improvement work to address the healthcare disparities associated with social determinants of health and the common chronic conditions that disproportionately impact the health of vulnerable communities in Michigan.

This project unites three impactful groups to drive change and improve lives.  First, the Michigan Health Information Network (MiHIN) is developing next generation interoperable data sharing infrastructure.  Second, the Blue Cross Blue Shield of Michigan (BCBSM) funded Collaborative Quality Initiative programs (CQIs) will use these clinical and social needs data in efforts to improve care through our data-driven learning health system.  Third, the CQIs will use value-based financial incentives (through BCBSM) to physicians and hospitals to augment utilization and partnership with existing community-based resources through a partnership with the Center for Health Research Transformation (CHRT).  Together, these groups represent an unmatched partnership for the at-risk population in Michigan.    

In collaboration with the Michigan Department of Health and Human Services, the Medicaid health information technology and exchange match grant from the U.S. Centers for Medicare and Medicaid Services (CMS) has two overarching goals:     
o    Help communities address social and clinical needs, improve health outcomes, and reduce disparities for Medicaid enrollees and other community members in six regions across the state.     
o    Develop, test, and scale interventions that address the social needs of Medicaid enrollees while identifying health disparities so physicians and community partners can address them.

Reducing Health Disparities 

The CQIs engage all hospitals and the vast majority of the physicians in Michigan. They function as a data-driven learning health system and have approximately 1000 full time staff devoted to improving care. The COVID-19 evidence made clear that Medicaid providers, beneficiaries, and the safety-net population will greatly benefit from these CQI efforts focusing on common chronic conditions that disproportionately impact the health of “at risk” patients, such as lung disease, diabetes mellitus, and chronic kidney disease. This reinforces the need for CQIs to incorporate the Social Determinants of Health (SDOH) data to clarify the fundamental gaps in optimal care delivery. These traditional medical specialty areas need better alignment and interaction with primary care and community-based services to fully empower a “next generation” of CQIs that can improve the population health and reduce health and healthcare disparities at a community level.    
 

The Promotion of Health Equity Project aims to reduce health disparities associated with pressing social needs such as housing instability, food insecurity, transportation, health system complexity, and other socioeconomic factors by:     
•    integrating clinical data with social needs data within CQI registries to help CQIs launch and monitor quality improvement initiatives targeting health disparities and social needs impacting patient care,    
•    supporting efforts to connect people from historically disadvantaged populations to needed social services,     
•    sharing data between relevant health and social service providers to facilitate improved care,     
•    providing population-based data and informatics to analysts, stakeholders, and policymakers, and    
•    better engaging with, and reflecting on the views of, community members with lived experience.

Core Partners 

•    Michigan Social Health Innovations to Eliminate Disparities (MSHIELD), a Collaborative Quality Improvement (CQI) initiative at Michigan Medicine, supported by Blue Cross Blue Shield of Michigan, whose mission is to empower CQIs to lead the future of quality improvement which achieves whole health for all people by integrating social care and clinical care, using data to drive health equity, and fostering a culture of anti-racism    
•    Obstetrics Initiative (OBI) a CQI with statewide collaboration across 70+ hospitals that optimizes maternity care experiences, health outcomes, and equity for Michigan families    
•    Michigan Data Collaborative (MDC), a data collection, aggregation, and reporting organization at the University of Michigan, which collects data from a variety of sources and delivers population-based reports     
•    Michigan Health Information Network (MiHIN), a nonprofit collaborative that securely stores patient health information and transmits relevant patient data to legally authorized health care providers    
•    Wayne State University, which connects CQIs and other end-users with Phoenix’s public facing resources and tools to build and visualize metrics to identify community gaps and disparities for Medicaid populations    
•    Center for Health and Research Transformation (CHRT), a nonprofit health research and policy center at the University of Michigan, which provides administrative support to the six participating Regional Health Collaboratives across Michigan:    
      o    Access Health    
      o    Health Net of West Michigan    
      o    Jackson Care hub    
      o    MI Community Care    
      o    Mid-Michigan Community Health Access Program    
      o    Southeastern Michigan Health Association

Michigan’s Regional Health Collaboratives  

The six Regional Health Collaboratives improve health and create healthcare savings by:    
•    Eliminating inefficiencies    
      o    Building networks of community-based health and social service providers to maximize resources, streamline processes, eliminate duplication of effort, and ensure seamless transitions of care.    
•    Improving interoperability    
      o    Connecting health information with social service information in a secure, trusted way to meet individual needs and support data-driven quality improvement efforts.

The regions are building capacity for a trusted, community-based workforce of ancillary providers, such as Community Health Workers and Community Paramedics, to partner with providers through integrated networks and shared technology to support place-based, patient-centered, and cost-effective care.     
 

This work includes identifying and addressing barriers to the expansion and sustainability of this workforce to build a reliable pipeline for recruiting, training, retaining, and elevating these professionals to serve a larger role in partnering with traditional healthcare.     
 

The CQIs enable hospitals and providers to work together to develop and implement data-driven best practices to improve care and address the most common, complex, and costly areas of surgical and medical care.     
 

Partnerships between the Regional Health Collaboratives and CQI participating providers, backed by MiHIN’s information exchange infrastructure, create an ideal structure to develop and pilot high-impact clinical and social health interventions to improve health outcomes and reduce the burden of chronic disease for Medicaid beneficiaries, while also supporting more equitable, higher-value care for all Michiganders.