Past Grants

Spectrum Health will develop a multidisciplinary team including a Registered Nurse or Care Manager and Community Health Worker (CHW) to target the barriers to chronic disease self-management in individuals who have recently experienced homelessness. Through this collaboration, thirty clients under risk-based contracts and receiving primary care through Spectrum Health’s Community Medical Clinic will be referred to Community Rebuilders to access affordable permanent housing and to Core Health to learn needed skills to self-manage their chronic health conditions. After accessing affordable permanent housing, Core Health will increase the support available to them by providing internet and smart devices to reduce barriers to care and connect individuals to other community resources. The goal is to allow clients with “smart homes” to access virtual/telehealth technology that can help them manage their physical and mental health needs in a direct, timely, and efficient manner with healthcare and other service providers. The project is using an equity centered design framework to engage clients through empathy interviewing techniques, journey mapping, surveys, and other assessment tools.