OTTAWA COUNTY, Mich. — In the last year of its pilot run, the Ottawa County Pathways to Better Health program is growing its staff and serving more clients. Officials anticipate it will continue for many years.

The program connects community health workers with adults who are eligible for, or enrolled in, Medicaid and have at least two chronic health conditions. The duo then establishes a “pathway” to care based on the client’s specific need.

“It can encompass everything,” said Nursing Supervisor Susan Keen. “It's mental healthcare, it's physical healthcare, it's just their overall health well being."

Workers have a list of 20 different pathways for clients, which include medical and social service referrals, housing assistance, family planning and education. Community health workers typically work with clients for six to nine months.

“[I] meet the clients where they are…pretty much wherever they feel the most comfortable,” said Shandra Smith, a community health worker who sees between 30-40 clients at a time. “My role is to walk alongside them, advocate and support for them regarding community resources they may be seeking that have been a barrier to health conditions they wish they’d been referred for.”

Pathways launched in February of 2017 as a three-year pilot program. More than 800 people have been referred over the first two years.

Most of the clients seek help for depression and anxiety, which overtook obesity as the top health issues in Ottawa County five years ago, according to a 2017 community health need assessment sponsored by the health department and other partners.

“We provide education on those chronic conditions, teaching people how to recognize it, how to maintain it, how to get treatment, all those things – and then we create the goals,” Smith said.

Clients are not charged for using Pathways. The program is funded by county hospitals, the health department and Ottawa Community Mental Health. Keen said she hopes the state will eventually recognize and reimburse the program.

“We feel it’s close,” she said. “The community health worker model is one that’s just a really important partner in the whole healthcare scene. They are able to provide the outreach and connection to the community that’s really so important.”

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