Driving Better Care Coordination and Delivery with Macomb Community Action



Healthify, powered by WellSky, is thrilled to welcome Macomb Community Action to the Michigan Community Network. For over 57 years, Macomb Community Action has been providing comprehensive educational, economic, and social services to children, adults, and seniors. 

The agency is on a mission to eliminate the causes and effects of poverty in Macomb County, Michigan where 9.2 percent of the population lives in poverty and more than 11.8 percent of residents are food insecure. For many, Macomb Community Action offers a lifeline—and after meeting with Executive Director Ernest Cawvey, we can understand why. Not only does the agency partner with hundreds of organizations across Macomb county, but they adapt their services to meet the rapidly changing needs of their residents.

In times of crisis, find solutions 

“Throughout the course of the pandemic, people who have never needed assistance in their life have found themselves in crisis, unsure where to turn,” says Cawvey.  

Some delayed services out of embarrassment. Some found themselves on hold, unable to reach an actual person. While the demand for services rose, people were not willing to go through an in-person intake process, which meant that the existing system had to change. 

Macomb Community Action took immediate action using a patient-centered approach. They created a new online portal. They accepted virtual intakes and photos of documents taken with smartphones. They even set up a dedicated phone line to assist residents with the application process and other prevalent needs.  

“We still have to do the full intake process, but just knowing your information is in the system offers peace of mind,” Cawvey says. It also helps to have passionate and knowledgeable people on the other side of the line, providing both compassion and expertise. 

Make rental assistance and home weatherization services more accessible  

In Southeast Michigan, residents have had to battle harsh weather conditions, in addition to COVID-19, and this has exasperated many problems for low-income residents, many of whom have outdated systems or are living in subpar or unsafe conditions. This also leads to higher utility bills, too, putting those in poverty at an even greater disadvantage.  

This is why Macomb Community Action offers a Weatherization Assistance Program, including wall insulation, furnace repair, and other energy-saving measures, as well as one of the largest emergency rental assistance programs in the country. The agency's COVID Emergency Rental Assistance (CERA) program includes rental and utility assistance to help maintain housing stability. When you are accepted into the program, you receive a complete assessment of your home environment and living conditions. From there, essential home services will be offered, including long-term investments on home repairs.  

Already, Macomb Community Action has spent $30 million through this program, which has been utilized by residents, landlords, and small business owners. 

“We make sure people have safe homes to live in,” says Cawvey—and that could mean replacing old carpets, repairing heating systems, doing ductwork, or adding wall insulation.  

To deliver better care, form a network 

When people are in crisis, they often need support paying rent, utilities, or other essential bills. Food pantries may not seem related, but often they are the first place where people turn, Cawvey explained, and the benefit is that anyone can utilize them, even if they are already enrolled in SNAP benefits. 

“If you’re having trouble making ends meet using a food pantry network can help reduce your food [and overall] budget,” explains Cawvey. It’s a safety net for many—and that’s why Macomb Community Action partners with more than 70 food pantries across the county. 

“One of the foundational principles of care coordination is that no one partner can do it alone,” says Cawvey. “For patients with complex care needs and especially those with SDoH needs, there is no one agency that can provide all of those services.” 

This is why community networks are so important. The best communities thrive when care is centered on the individual and coordinated across different sectors and organizations. The challenge is achieving that close loop.  

Recognize the unique role of healthcare-community partnerships  

When you’re living in poverty or facing social barriers, you may delay care or skip routine doctor’s visits—and this is far too often the case for Medicaid patients, many of whom don’t have an established primary care physician or underutilize preventative services.  

Payers have a unique opportunity that providers don’t, Cawvey explains. By partnering with social service agencies, payers can address SDoH issues more proactively and enable patients to better manage their prescribed care.  

If you are reactionary, you are only going to exacerbate needs, Cawvey says. In order to see a return on investment, Cawvey believes there needs to be more contribution as opposed to attribution. When everyone contributes, more benefits will result—and this will equate to lower costs of care, better managed chronic disease, and more optimal health outcomes.  

Topics: healthcare delivery Medicaid community-based organizations care coordination SDoH interventions SDoH partnerships sdoh

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