Greater flint health coalition's community information exchange - greater flint health coalition and the genesee community health access program (chap) will establish and expand a community…

Greater flint health coalition's community information exchange - greater flint health coalition and the genesee community health access program (chap) will establish and expand a community information exchange in the 5TH congressional district to support cross-sector care access and navigation to address mental health prevention and treatment needs of residents, including the facilitation of direct outreach, navigation, and clinical community linkage systems. The proposed community information exchange will facilitate the integration of multiple health care, behavioral health, and community service providers to: 1) identify residents or patients with a high burden of unmet behavioral health or social needs; 2) provide patient-centered, coordinated care management, navigation, and community linkage services to ensure residents are connected to community and social service resources while having support to maintain engagement in critical medical home and behavioral health services; 3) deliver social health interventions at the person, provider, and system levels via the deployment of an evidence based, community health worker team; and 4) enhance integration and data collection via a community-wide screening, referral, and clinical community linkage system positioned to address the unmet and diverse social determinant of health needs of the population.