What is the program?

Over the past 12 months, St. Mary’s of Michigan and its Center of HOPE’s clinical team and community health workers have determined there is an unmet need in the Saginaw region for access to comprehensive, wrap-around care as a means to reduce health disparities in obesity, diabetes and hypertension. Commonly the need for these services is for seniors living independently in our community. In order to reduce these disparities, the Center of HOPE Community Health Workers currently provide to 100 individuals preventative screenings for obesity, diabetes, and hypertension education, including the proper use of insulin and other diabetic supplies, follow-up care, and proper diet and nutrition. These services are delivered in a culturally sensitive way and appropriate for all literacy levels.

Through the use of Center of HOPE’s Population Health Management program, Community Health Workers work closely with the patient’s care team of providers and participants receive personalized plans in order to support successful outcomes through goal setting, weekly/monthly visits, and a personalized assessment to identify health barriers. In order to achieve success, the Center of HOPE Community Health Worker is integrated in the participant’s primary care services. The Center of HOPE also offers numerous free educational programs and support services to enhance the participant’s experience, both in the participant’s home and at St. Mary’s Center of HOPE facility, in a very positive and healthy environment in order to achieve success.

The St. Mary’s of Michigan Center of HOPE is a unique mission outreach program offering a “one-stop-shop” for Saginaw County residents who are in need of assistance. The Center of HOPE offers access to numerous healthcare services to Saginaw County’s uninsured and underinsured including:

• A fully-licensed, charitable Community Benefit Pharmacy, operated by a licensed pharmacist

• Free Medical Clinics – two free clinics located in Saginaw, including the Hunger Solution Center

• Health education classes taught by registered nurses and community health workers

• Community Health Workers providing patients with links to various health and human service resources including medical treatment, health plan enrollment, transportation needs, prescription program enrollment, and important follow-up planning

• A laundry facility

• An exercise room, walking club, and yoga

• Summer Children’s Program and a children’s reading corner and separate playroom

How will grant dollars be used?

In order to provide such life-saving community outreach and supportive services to the region’s diabetic, obese and hypertensive patients, St. Mary’s of Michigan Center of HOPE will expand its Population Health Management program to assist Saginaw patients who receive hospital care for obesity, hypertension, diabetes, bariatric surgery and wound care. This comprehensive program expansion will target a total of over 200 individuals residing in Saginaw County. The program will monitor individuals on a daily, weekly or monthly basis through personalized home visits, education programs, diabetic and hypertension education, including the proper use of insulin and other diabetic supplies, follow-up care, along with proper diet, nutrition and exercise.

Who do they collaborate with?

St. Mary’s of Michigan Center of HOPE works closely with MSU Extension to provide nutrition classes and diabetes prevention programming. They also incorporate healthier diet choices through the promotion of how to wisely spend their dollars on fresh fruits, vegetables, and/or fruit and vegetable plants at the Downtown Saginaw Farmers Market. With the expansion of the Downtown Saginaw Farmers Market and the addition of a demonstration kitchen, participants will be able to attend demonstrations on how to prepare and preserve items purchased at the market. The Center of HOPE will also be working with the YMCA of Saginaw to become a partner site for the Saginaw YMCA to expand their MEND Initiative to address chronic disease prevention programs for adults and seniors through taking strides forward with physical activity.

What’s the plan for sustainability?

The St. Mary’s of Michigan Center of HOPE Population Health Management program will continue to expand its integrative program. As statistics show, chronic health diseases are a growing epidemic. This program will offer its inaugural participants the hands-on tools and resources, plus qualified medical team members to provide educational outreach. Successful completion of the program will also mean additional regional and statewide funding opportunities to seek for program expansion. Furthermore, the Saginaw Community Foundation encourages St. Mary’s of Michigan Center of HOPE to apply for grant funding through the Senior Citizen Enrichment Fund, a fund established with the purpose of enhancing the lives of seniors living an independent lifestyle in Saginaw County.