About the CHIR 

The Greater Flint Health Coalition (GFHC) is one of five organizations chosen by the Michigan Department of Health and Human Services (MDHHS) to lead the implementation of the State Innovation Model (SIM) within their communities.


Established in 1996, the Greater Flint Health Coalition (GHFC) is a Flint, Michigan-based non-profit collective impact organization and partnership between Genesee County hospitals, physicians, businesses, insurers, public health professionals, policymakers, government leaders, educators, organized labor, community organizations, residents, and all those concerned about the well-being of our community and its residents.

The two-fold mission of the Greater Flint Health Coalition is to improve the health status of Genesee County residents and to improve the quality and cost-effectiveness of the health care system in the community.

Through serving those living in Flint and Genesee County, the vision of GFHC is a healthy Genesee County community practicing healthy lifestyles with access to the best and most cost-effective health and medical care. As Genesee County’s neutral convener and backbone support organization for community, public health, and health care initiatives, the Greater Flint Health Coalition works together to achieve collective impact to improve the health status of Flint & Genesee County residents.

Currently, the GFHC is the neutral convener of 25 multi-sector coalitions in the following focus areas: Health Improvement, Access & Environment, Quality & Innovation, Cost & Resource Planning, Sector Workforce Development, Racial Disparities and Health Equity  In addition to its convener role, the GFHC also operates a variety of community-based programs including Commit to Fit, Genesee Community Health Access Program (CHAP), Connecting Kids to Coverage, and the Flint Healthcare Employment Opportunities (FHEO) Program.

For more information about the Greater Flint Health Coalition please visit its website at

CHIR Goals and Strategies

As the backbone organization for the Genesee Community Health Innovation Region (CHIR), the Greater Flint Health Coalition is working to enhance cross-sector partnerships that impact population health and connect patients with relevant community and social services that address the social determinants of health (SDOH). As part of the State Innovation Model, the Genesee CHIR seeks to:

  • Reduce “inappropriate” and preventable emergency department utilization;
  • Address unmet social needs;
  • Enhance clinical-community linkages via a functional Community Referral Network; and
  • Reduce health disparities and improve health equity.

Greater Flint Health Coalition Community Referral Network picture

The Genesee CHIR is launching a paradigm change promoting a new and more complex understanding of health and the importance of social determinants of health.

The Genesee CHIR is also creating a collective innovation space providing opportunities for health and social services to depart from business as usual and pioneer new and different ways of working together.

Current Efforts

Clinical Community Linkage Initiative

To address non-medical factors that affect health, such as housing, transportation, and food insecurity, the Genesee CHIR has implemented its Clinical Community Linkage Initiative to support connections between primary care practices and community service providers. The Genesee CHIR’s Clinical-Community Linkage (CCL) Hub model is based upon the Greater Flint Health Coalition’s successful, evidence-based, best practice model, Genesee CHAP (Community Health Access Program).

SIM Clinical-Community Linkage Initiative (1 SDOH)

Clinical Community Linkage (2 Process)

The Genesee CHIR’s CCL Hub employs community health workers (CHWs) to engage the individuals referred, identify their health priorities and needs, and link them to services and resources in the community to meet those needs. These CHWs are based at the four CCL Specialty Hubs: Genesee CHAP, Genesee Health Plan, Genesee Health System, and New Paths (a substance use recovery organization). 

Social Determinants of Health (SDOH) Needs

The Genesee CHIR has implemented a community-wide SDOH screening strategy. A standardized screening tool has been embedded into local SIM PCMH practice electronic health record systems or care coordination platforms. The current SDOH screening tool assesses for needs related to food insecurity, utilities, housing, child care, healthcare access, transportation, health literacy, safety, substance use information, depression, access to clean water, employment, and education/job training. SDOH screens are administered to patients presenting for a primary care office visit. The Genesee CHIR’s CCL Hub supports PCMH practices administering the SDOH screens in connecting their patients to community resources.

SDOH results are fed monthly into a central repository operated by the regional health information exchange, Great Lakes Health Connect, with Greater Flint Health Coalition oversight. Genesee CHIR partners are utilizing analyses of the SDOH screens to identify and address areas of need lacking resources, as well as to inform the Community Health Needs Assessment and development of a Community Health Improvement Plan.

Community Referral Platform Technology

The Genesee CHIR has implemented an electronic Community Referral Platform to make, track, and close the loop on referrals the CCL Hub receives and makes. In addition to partnering PCMH practices making referrals to the CHIR’s CCL Hub over the Community Referral Platform, Community Service Provider Organizations are receiving referrals from the CCL Hub’s four Specialty Hubs by the same technology.

SIM CHAP Referral


For more information: 
Lori Kunkel, 810-232-2228