Saginaw Pathways to Better Health

Healthcare delivery for chronic conditions can be complex, especially for individuals with multiple chronic illnesses.­ The Saginaw Pathways to Better Health project minimizes barriers by creating a strong partnership among healthcare and social services providers, agencies serving special populations and other stakeholders.­ Saginaw Pathways to Better Health ensure that patients have access to the services they need and reduces unnecessary duplication of resources and services.

Community Health Workers (CHW) are recruited from the local community and receive specialized training as well as supervision from a nurse and a social worker.­ A CHW is then assigned to each patient who will partner with their healthcare providers, or, if needed, help connect them to a medical home.­ The CHW will also help educate patients about their conditions, promote healthy behaviors, and facility access to needed health and social services through the appropriate pathway.

These pathways include:

  • Social services (such as assistance with food, housing, transportation, education, medical debt, legal affairs, utilities, or domestic violence);
  • Medical services (including primary and specialty care, dental, vision, hearing, family planning, mental health care, substance abuse treatment, speech and language and pharmacy services);
  • Help with insurance, cessation of tobacco use/smoking, and medication assessment and management.