Public health departments across Michigan are taking important steps to improve how residents access essential services that influence long-term well-being. By strengthening technology partnerships and modernizing referral workflows, agencies are better equipped to address healthcare access, along with the broader social and community factors that shape outcomes.
Patagonia Health is proud to support this work by enabling public health teams to screen for social determinants of health needs and connect individuals directly to services within their electronic health records.
Supporting Michigan’s SDOH Strategy
In 2022, the Michigan Department of Health and Human Services launched its 2022-2024 Social Determinants of Health Strategy. The initiative focuses on addressing non-medical factors, including housing, transportation, and food insecurity. These issues are deeply tied to community context and overall health outcomes.
As part of this statewide effort, SDOH Hub pilot sites began in April 2024. The Hub is led locally by Heart of West Michigan United Way and supported by a Community Information Exchange developed by the Brightstreet Group. Its goal is to reduce barriers to social support services and improve access to food assistance and other resources.
A central component of this initiative is Michigan 2-1-1, a free and confidential service that connects residents to thousands of local health and human service resources. To fully participate in the Hub, health departments needed a secure and seamless way to connect their EHR with the statewide referral network.
Closing the Loop on Social Determinants of Health Support
To meet this need and support public health departments participating in Michigan’s SDOH Hub, Patagonia Health developed a new SDOH screener and referral integration within its EHR.
The screener captures key social needs, including food insecurity, transportation, education, immediate needs, and Medicaid coverage. When a need is identified, referrals are automatically triggered within the system, eliminating extra steps for health department staff.
Using a FHIR-based interface, referrals are created simultaneously in Patagonia Health’s EHR and the SDOH Hub. As community partners acknowledge or complete referrals in the Hub, status updates are transmitted back to Patagonia Health in real-time. This keeps both systems aligned and removes the need for manual tracking.
Only the minimum required data is exchanged, with robust safeguards in place to ensure responsible information sharing and protection of consent and privacy.
Benefits for Public Health Staff
By replacing manual workflows with an automated, closed-loop referral system, the integration between Patagonia Health’s EHR and Michigan’s SDOH Hub has improved efficiency for public health teams. Community health workers spend less time tracking referrals and more time supporting individuals and families.
The EHR also enables staff to set follow-up reminders, helping ensure timely outreach and continuity of care. These improvements support better access to and quality of healthcare, as well as improved outcomes related to social determinants of health.
Most importantly, individuals experiencing food insecurity and other social needs are connected to services more quickly, helping advance health equity across Michigan communities.
Looking Ahead: A Scalable Model for Addressing SDOH
By leveraging Patagonia Health’s EHR, public health departments can establish a sustainable framework for addressing current and future social determinants of health priorities. As other states create opportunities to meet the objectives outlined in Healthy People 2030, Patagonia Health and partners can expand to support additional needs. This could include housing stability and non-emergency medical transportation.
“True community impact happens when technology brings partners together instead of creating new barriers. By uniting United Way, Michigan 2-1-1, and local health departments through flexible, interoperable technology, we are helping staff focus their time where it matters most: supporting patients rather than managing administrative tasks. This approach strengthens collaboration, respects existing workflows, and makes closed-loop referrals achievable without adding unnecessary complexity.”
— Jolie Rollins, Sales Engineer, Patagonia Health
